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PHTLS_ Prehospital Trauma Life Support 8TH

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Published by patrasyounas_younasbarkat, 2022-07-12 06:31:55

PHTLS_ Prehospital Trauma Life Support 8TH

PHTLS_ Prehospital Trauma Life Support 8TH

318 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

The patient is moved upward and laterally onto . . The patient is positioned onto t he long
• t he long backboard. Neutral in-line stabilization
~ backboard with the head at the top of the
is maintained without pulling on the patient's
head and neck. board and the body centered and secured to
the device.

B. Prone or Semi-prone Patient

When a patient presents in a prone or semi-prone position, a st abilization method similar to that used for t he supine patient
can be used. The method incorporates the same init ial alignment of the patient's limbs, the same positioning and hand place-
ment of the prehospital care providers, and the same responsibilities for maintaining alignment.

The patient's arms are positioned in anticipation of the f ull rotation that w ill occur. When using the semi-prone logroll
method, a cervical collar can be safely applied only after the patient is in an in-line position and supine on t he long backboard,
not before.

Whenever possible, the patient should be
• rolled away from the direction in which the

patient's face initially points. One prehospital
care provider establishes in-line manual
stabilizat ion of the patient's head and neck.
Another prehospital care provider kneels at the
patient's thorax and grasps the patient's opposite
shoulder and wrist and pelvis area. A third
prehospital care provider kneels at the patient's
knees and grasps t he patient's wrist and pelvis
area and lower extremities.

CHAPTER 11 Spinal Trauma 319

Spine Management CcontinuedJ

The long backboard is placed on the lateral edge The board is placed with the foot of the board
• and brought into position between the patient • between the patient's knees and ankles, and

and the prehospital care providers. the pat ient is logrolled onto his or her side.
The patient's head rotates less than the torso,
so by the time the patient is on his or her side
(perpendicular to the ground), the head and
torso have come into proper alignment.

Once the patient is supine on the long
• backboard, the patient is moved upward and

toward the center of the board. The prehospital
care providers shou ld take care not to pull
the patient but to maintain neutral in-line
stabilization. Once the patient is positioned
properly on the long backboard, a properly sized
cervica l collar can be applied, and the patient
can be secured to the backboard.

3 2 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

Sitting Immobilization (Vest-Type Extrication Device)

Principle: To immobilize a trauma patient without critical injuries before moving the
patient from a sitting position.

This type of immobilization is used when spinal stabilization is indicated for a sitting trauma patient w ithout life-t hreatening
conditions. Several brands of vest-type extrication devices are available. Each model is slight ly different in design, but any
model can serve as a general example. The Kendrick Extrication Device (KEO) is used in this demonst ration. The details (but
not the general sequence) are modified when using a different model or brand of ext rication device. Also, during this demon-
stration, the w indshield of the vehicle has been removed for clarification purposes.

• M anual in-line stabilization is initiated and a The pat ient is maintained in an upright posit ion
properly sized cervical collar applied. • slightly forward t o provide an adequate amount

of space between the patient's back and the
vehicle seat for placement of t he vest-type
device. Note: Before placing the vest-type device
behind the patient, the two long straps (groin
straps) are unfastened and placed behind the
vest device.

CHAPTER 11 Spinal Trauma 321

Spine Management CcontinuedJ

After placing the vest device behind the patient, The torso straps are positioned and fastened,
• the side flaps are placed around the patient • starting with the middle chest strap and

and moved until the side flaps are touching the followed by the low er chest strap. Each strap is
patient's armpits. tightened after attachment. Use of the upper
chest strap at t his time is optional. If the upper
chest strap is used, the prehospital care provider
should ensure that it is not so t ight that it
impedes the patient's ventilations. The upper
chest strap should be tightened just before
moving the patient.

Each groin strap is positioned and fastened .
• Using a back-and-forth motion, each strap is

worked under the pat ient's thigh and buttock
until it is in a straight line in the intergluteal fold
from front to back. Each groin strap is placed
under the patient's leg and attached to the vest
on the same side as the strap's origin. Once in
place, each groin strap is tightened. The patient 's
genitalia should not be placed under the straps
but to the side of each strap.

3 2 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

Padding is placed between the patient's head The patient's head is secured to the head flaps
• and the vest to maintain neutral alignment. • of the vest device. The prehospital care provider

should be careful not to seat the patient's
mandible or obstruct the airway. Note: The torso
straps should be evaluated and readjusted as
needed .

~ All straps should be rechecked before moving • If possible, the ambulance cot with a long
~ t he pat ient. If the upper chest strap has not been backboard should be brought to the opening of
the vehicle door. The long backboard is placed
secured, it should be attached and tightened . under the patient's buttocks so that one end
is securely supported on the vehicle seat and
the other end on the ambulance cot. If t he
ambulance cot is not available or t he terrain
will not allow t he placement of the cot, other
prehospital care providers can hold the long
backboard while the pat ient is rotated and lifted
out of the vehicle.

CHAPTER 11 Spinal Trauma 3 2 3

Spine Management CcontinuedJ

~ While rotating the patient, the patient's lower • Once the patient is rotated with his or her
~ extremities must be elevated onto the seat. If the back to the center of the long backboard, the
patient is lowered to the board while keeping
vehicle has a cent er console, the patient's legs the legs elevated. After placing the patient
should be moved over the console one at a time. onto the long backboard, the two groin straps
are released and the patient's legs are lowered.
The patient is positioned by moving him or her
up on the board with the vest device in place.
The prehospital care provider should consider
releasing the upper chest strap at this time.
Once the patient is positioned on the long
backboard, the vest device is left secured in place
to continue to immobilize the patient's head,
neck, and torso. The patient and vest device are
secured to the long backboard. The patient's
lower extremities are immobilized to the board,
and the long backboard is secured to the ambu-
lance cot.

3 2 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

Rapid Extrication

Principle: To manually stabilize a patient with critical injuries before and during
movement from a sitting position.

A. Three or More Prehospital Care Providers

Sitting patients with life-threatening conditions and indications for spinal immobilization (see Figure 11-14) can be rapidly ext ri-
cated. Immobilization to an interim device before moving the patient provides more stable immobilization than when using
only the manual (rapid extricat ion) method. How ever, it requires an additional 4 to 8 minutes to complete. The prehospital care
provider will use the vest or halfboard methods when (1) the scene and patient's condition are stable and time is not a primary
concern or (2) a special rescue situation involving substantial lifting or technical rescue hoisting exists, and significant move-
ment or carrying of the patient is involved before it is practical to complete the supine immobilization to a long backboard.

Rapid extrication is indicated in the following situations:
• When the patient has life-threatening conditions identif ied during the primary assessment that cannot be corrected

where the patient is found
• When the scene is unsafe and clear danger to the prehospital care provider and patient exists, necessitat ing rapid

removal to a safe location
• When the patient needs to be moved quickly to access other, more seriously injured patients
Note: Rapid extrication is selected only when life-threatening conditions are present and not on t he basis of personal preference.

• Once the decision is made to extricate a patient While manual stabilization is maintained, t he
rapidly, manual in-line stabilization of the • patient's upper torso and lower torso and legs
patient's head and neck in a neutral position
is initiated. This is best accomplished from are controlled. The patient is rotated in a series
behind the patient. If a prehospital care provider of short, controlled movements.
is unable to get behind the patient, manual
stabilizat ion can be accomplished from the
side. Whether from behind the patient or the
side, the patient's head and neck are brought
into a neutral alignment, a rapid assessment of
t he patient is performed, and a properly sized
cervical collar is applied.

CHAPTER 11 Spinal Trauma 3 2 5

Spine Management CcontinuedJ

If the vehicle has a center console, the patient's The prehospital care provider continues t o rotate
legs should be moved one at a time over the • the patient in short controlled movements until
console.
control of manual stabil ization can no longer be
maintained from behind and inside the vehicle.
A second prehospital care provider assumes
manual stabilization from the first prehospital
care provider while standing outside of the
vehicle.

The first prehospital care provider can now The rotation of the patient is continued until the
• move outside the vehicle and reassume manual • patient can be lowered out of the vehicle door

stabilizat ion from the second prehospital care opening and onto the long backboard.
provider.

3 2 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

The long backboard is placed with the foot end . . Once the patient's torso is down on the board,
• of the board on the vehicle seat and the head
~ the weight of the patient's chest is controlled

end on the ambulance cot. If the cot cannot be while t he patient's pelvis and lower legs are

placed next to the vehicle, other prehospital care controlled. The patient is moved upward onto

providers can hold the long backboard wh ile the the long backboard. The prehospital care

patient is lowered onto it. provider who is maintaining manual stabilization

is careful not to pull the patient but to support

the patient's head and neck.

After the patient is positioned onto the long

backboard, the prehospital care providers can

secure the patient to the board and the board to

the ambulance cot. The patient's upper torso is

secured first, then the lower torso and pelvis area,

then the head. The patient's legs are secured

last. If the scene is unsafe, t he patient should be

moved to a safe area before being secured to the

board or cot.

Note: This procedure represents only one example of rapid extrication. Because very few field situations are ideal, prehospital
care providers may need to modify the steps for extrication for the particular patient and situation. The principle of rapid extri-
cation should remain the same regardless of the situation: Maintain manual stabilization throughout the extrication process
without interruption, and maintain the entire spine in an in-line position without unwarranted movement. Any positioning of
the prehospital care providers that works can be successful. However, numerous position changes and hand position takeovers
should be avoided because t hey invite a lapse in manual stabilization.

The rapid extrication technique can effectively provide manual in-line stabilization of the patient's head, neck, and torso
throughout a patient's removal from a vehicle. The following are three key points of rapid extrication:

1. One prehospital care provider maintains stabilization of the patient's head and neck at all times, another rotates
and stabilizes the patient's upper torso, and a third moves and controls the patient's lower torso, pelvis, and lower
extremities.

CHAPTER 11 Spinal Trauma 327

Spine Management CcontinuedJ

2. Maintaining manual in-line stabilization of the patient's head and neck is impossible if attempting to move t he patient
in one continuous motion. The prehospita l care providers need to limit each movement, stopping to reposit ion and
prepare for the next move. Undue haste w ill cause delay and may result in movement of the spine.

3. Each situation and patient may require adaptation of the principles of rapid extricat ion. This can only work effectively
if the maneuvers are practiced. Each prehospital care provider needs to know the actions and movements of the ot her
prehospital care providers.

B. Two Prehospital Care Providers

In some situations an adequate number of prehospital care providers may not be available to extricate a crit ical patient rapidly.
In these situations a tw o-provider technique is useful.

• One prehospital care provider initiates and The patient is t urned using the ends of the
maintains manual in-line stabilization of the • blanket roll and until the patient's back is
patient's head and neck. A second prehospital
care provider places a properly sized cervical centered on the door opening.
collar on the patient and places a prerolled
blanket around the patient. The center of the
blanket roll is placed at the patient's midline on
t he rigid cervical collar. The ends of the blanket
roll are wrapped around the cervical collar and
placed under the pat ient's arms.

3 2 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management CcontinuedJ

The first prehospital care provider takes control
• of the blanket ends, moving them under the

patient's shoulders, and moves the pat ient by
t he blanket while the second prehospital care
provider moves and controls t he patient's lower
torso, pelvis, and legs.

Child Immobilization Device

Principle: To provide spinal immobilization to a child with a suspected spinal injury.

The first prehospital care provider kneels above The second prehospital care provider now kneels

• t he patient's head and provides manual in-line • at the patient's side between the shoulders and

stabilization of the patient's head and neck. The knees. The second prehospital care provider

second prehospital care provider sizes and applies grasps t he patient at the shoulder and hips in

a cervical collar while the first prehospital care such a fashion as to maintain a neutral in-line

provider maintains neutral in-line stabilization. position of the lower extremities. On command

The second prehospita l care provider straightens from the first prehospital care provider, the

t he patient's arms and legs, if needed. patient is logrolled slightly onto his or her side.

CHAPTER 11 Spinal Trauma 329

Spine Management CcontinuedJ

A third prehospital care provider positions the /
• immobilization device behind the patient and
The device is held against the patient's back and
holds it in place. • the patient is logrolled onto t he device, and the

device is lowered to t he ground w ith the patient.

•The patient is now secured to the immobilizat ion After securing the pat ient's torso and lower
ext remities to the immobilization device, t he
• device by the second and third prehospital care patient's head is secured to the immobilization
provider while the first prehospital care provider
maintains head and neck stabilization. device .

3 3 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Spine Management ccantinuedJ

Helmet Removal

Principle: To remove a safety helmet while minimizing the risk of additional injury.

Patients who are wearing full-face helmets must have the helmet removed early in the assessment process. This provides imme-
diate access for the prehospital care provider to assess and manage a patient's airway and ventilatory stat us. Helmet removal
ensures that hidden bleeding is not occurring into the posterior helmet and allows the prehospital care provider to move t he
head (from the flexed position caused by large helmets) into neutral alignment. It also permits complete assessment of t he
head and neck in the secondary assessment and faci litates spinal immobilization when indicated (see Figure 11-14). The pre-
hospital care provider explains to the patient what will occur. If the patient verbalizes that the prehospital care provider should
not remove the helmet, the prehospital care provider will explain that properly trained personnel ca n remove it by protect ing
the patient's spine. Two prehospital care providers are required for t his maneuver.

One prehospital care provider takes a position The patient's mandible is grasped between the
• above the patient's head. With palms pressed • thumb and the first tw o fingers at the angle of

on the sides of the helmet and fingertips curled the mandible. The other hand is placed under
o ver the lower margin, the first prehospital the pat ient's neck on the occiput of t he skull
care provider stabilizes the helmet, head, and to take control of manual stabilization. The
neck in as close to a neutral in-line position as prehospital care provider's forearms should be
t he helmet allows. A second prehospital care resting on the floor or ground or on his or her
provider kneels at the side of the patient, opens own thighs for additional support.
or removes t he face shield if needed, removes
eyeglasses if present , and unfastens or cuts the
ch in strap.

CHAPTER 11 Spinal Trauma 331

Spine Management CcontinuedJ

The first prehospital care provider pulls the • Once the helmet is removed, padding should be
• sides of the helmet slightly apart, away from placed behind the pat ient's head to maintain a
neutral in-line position. Manual stabilization is
t he patient's head, and rotates t he helmet with maintained, and a properly sized cervical collar is
up-and-down rocking motions while pull ing placed on the patient.
it off of the patient's head. Movement of the
helmet is slow and deliberate. The prehospital
care provider takes care as the helmet clears the
patient's nose.

Note: Two key elements are involved in helmet remova l, as follows:

1. While one prehospital care provider maintains manual stabilization of the patient's head and neck, t he other prehos-
pital care provider moves. At no time should both prehospital care providers be moving their hands.

2. The prehospital care provider rotates the helmet in different directions, first to clear the pat ient's nose and then to
clear the back of the patient's head.

Vacuum Splint Application

It is important to take proper care when using a vacuum mattress. Any sharp object on the ground or in the patient's clothes
may pierce the mattress, rendering it useless.

The steps involved in applyi ng a vacuum splint may vary from t he following steps, depending upon the particular vacuum
mattress available. Prehospital care providers should become familiar wit h t he steps specific to the particular device used in
their agency.

332 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION ,...,
g
Spine Management CcontinuedJ
~
,...,
g 2.

~ ,<..

2. ~
g)>_
it
"~-
'ill
Ol

,~3,.

)>
@
0..

~

,<..

~
g)>_

"~-

A prehospital care provider places a vacuum A scoop stretcher is used to transfer the patient
• mattress on a lowered stretcher. The mattress • onto the vacuum mattress.

should be deflated partially w ith the valve of
the mattress at the head. The plastic balls
inside the mattress should be spread out evenly
and form a relatively f lat surface. A prehospital
care provider then places a sheet on the vacuum
mattress.

CHAPTER 11 Spinal Trauma 333

Spine Management CcontinuedJ "g
~
"g
~ 2.

2. ,<..

it ~
g)>_
'ill
Ol "~-

,~3,.

)>
@
0..

~

,<..

~
g)>_

"~-

The vacuum mattress is molded to the body
• contours of the patient while one prehospital

care provider maintains manual in-line
stabilization of the patient's head. Once the
mattress is molded to the patient, the valve of
the vacuum mattress is opened and suction is
applied to deflate the mattress.

The scoop stretcher is removed carefully from
• beneath the patient.

Then the valve is closed and the patient secured
• with belts. A sheet or blanket should be placed

over the patient.

At the completion of this chapter, the reader will be able to do the following:

• Discuss the normal anatomy and physiology of • Relate the signs, symptoms, pathophysiology, and
the thoracic organs. management of the following specific thoracic
inj uries:
• Explain the alterations in anatomy and physiology
that result from thoracic injury. • Rib fractures
• Flail chest
• Discuss the relationships among the kinematics • Pulmonary contusion
of trauma, thoracic anatomy and physiology, and • Pneumothorax (simple, open, and closed)
various assessment findings, leading to an index • Tension pneumothorax
of suspicion for various injuries. • Hemothorax
• Blunt cardiac injury
• Differentiate between patients in need of rapid • Cardiac tamponade
stabilization and transport and patients in w hom • Commotio cordis
fu rther on-scene assessment and management is
warranted o r appropriate. Traumatic aortic disruption

• Discuss the impact of an urban or suburban •• Tracheobronchial disruption
and rural or austere setting on assessment and • Traumatic asphyxia
management of t horacic injury. • Diaphragmatic rupture

CHAPTER 12 Thoracic Trauma 3 3 5

You and your partner are dispatched t o an industrial construction area for a w orker who was struck by a piece of metal. Upon arrival,
you are met at the gate by the site safety officer, who leads you to an interior work area. En route to the work area, t he safety officer
states t he patient w as helping to install metal st uds. When he turned to grab another stud, he ran into the end of a stud his partner had
just trimmed, cutting through his sh irt and puncturing his chest.

In the w ork area, you find an approximately 35-year-old man sitting upright on a pile of lumber, leaning forward and holding a rag
to t he right side of his chest. You ask t he patient what happened, and he t ries to tell you but has to stop after every five to six words to
catch his breat h. As you move the rag, you notice an open laceration approximately 2 inches (5 centimeters) long w ith a small amount
of blood-tinged, "bubbling" fluid. The patient is diaphoretic and has a rapid radial pulse. Decreased breath sounds are noted on t he
right side with auscultation. No other abnormal physical findings are noted.

• Is this patient in respiratory distress?
• Does he have life-threatening injuries?
• What interventions should you undertake in the field?
• What modal ity shou ld be used to transport this patient ?
• How would a different location (e.g., rural) impact your management and plans during prolonged transport?
• What other injuries do you suspect?

can result from blunt or penetrating mecha- chest injury in the short term and thereby contribute to late com-
nisms. Blunt force applied to the thoracic cage in motor vehicle plications, such as multisystem organ failure which accounts for
crashes, high falls, beatings, or crush injuries can cause dis- the 25%of trauma deaths that result from thoracic injury.rn
ruption of the normal anatomy and physiology of the thoracic
organs. Similarly, penetrating wounds from gunshots, knives, Anatomy
or impalement on objects such as rebar can injure the tho-
rax. Definitive management of most thoracic injuries does not The chest is roughly a hollow cylinder formed by its bony and
require tlwracotomy (opening the chest cavity operatively). In muscular structures. There are 12 paired ribs. The upper 10 pairs
fact, only 15% t o 20% of all chest injuries require thoracotomy. attach to the spinal column in the back and either the sternum or
The remaining 85% are well managed with relatively simple the rib above in the front. The lower two pairs of ribs attach only
interventions, such as supplemental oxygen, ventilatory sup- in back to the spine. In the front they are free and thus referred
port, analgesia, and tube tlwracostomy (chest tube placement) to as "floating ribs." This bony cage provides a great deal of pro-
when necessary.1-11 tection to the internal organs of the chest cavity and, thanks to
the lower ribs, even shields the organs of the upper abdomen
Nevertheless, thoracic injuries can be quite significant. (most notably the spleen and liver). This framework of ribs is
The thoracic organs are intimately involved in the maintenance reinforced with muscle. The intercostal muscles lie between
of oxygenation, ventilation, and perfusion and oxygen deliv- and connect the ribs to one another.
ery. Injury to t he chest, especially if not promptly recognized
and appropriately managed, can lead to significant morbidity. A number of muscle groups move the upper extremity and
Hypoxia (insufficient oxygen in the blood), hypercarbia (exces- are part ofthe chest wall, including the major and minor pectoral
sive carbon dioxide in the blood), acidosis (excessive acid in muscles, anterior and posterior serratus muscles, and latissi-
the blood), and shock (insufficient oxygen reaching the body's mus dorsi muscles, along with the various muscles of the back
organs and tissues) can result from inadequate management of (Figure 12-1). All this "padding" means it takes a considerable
amount offorce to injure the internal organs.

Also found in the thorax are muscles involved in the process
of breathing (ventilation), including the intercostal muscles; the

336 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Esophagus

Orbicularis oris Pectoralis lntercostal left
major muscle pleural
Biceps brachii Serratus cavity
Brachialis anterior Visceral left lung
pleura
Rectus abdominis Linea Pleural
Internal oblique alba Parietal space
External oblique pleura
Heart and
mediastinum

Adductor
magnus

Quadriceps { Rectus femoris Figure 12-2 The thoracic cavity, including the ribs, intercostal
femoris Vastus lateralis muscles. diaphragm, mediastinum. lungs. heart, great vessels.
Vastus medialis---...-- bronchi, trachea, and esophagus.

Source: Background image © Mariya L/ShutterStock.

Physiology

Anterior view The two components of chest physiology that are most likely
to be impacted by injury are breathing and circulation.1-3 Both
Figure 12-1 The muscular system. processes need to be working properly and in coltjunction with
one another for oxygen to reach the body's organs, tissues, and
Source: Background image© Carol and Mike Werner/Science Source. ultimately cells and to expel carbon dioxide. To best understand
what happens to patients when their chests are injured and how
to manage their injuries, it is important to understand the physi-
ology of these two processes.

diaphragm, which is a dome-shaped muscle attached around the Ventilation
lower aspect of the chest; and muscles in the neck that attach
to upper ribs. An artery, vein, and nerve course along the lower The lay terms "breathing" and "respiration" actually refer
edge of each rib and provide blood and stimulation to the inter- to the physiologic process of ventilation. Ventilation is the
costal muscles. mechanical act of drawing air through the mouth and nose
into the trachea and bronchi and then into the lungs, where it
Lining the cavity formed by these structures is a arrives in small air sacs known as alveoli. Respiration is ven-
thin membrane called the parietal pleura. A matching thin tilation plus the delivery of oxygen to the cells. The process of
membrane covers the two lungs within the chest cavity, called drawing air in is called inhalation. Oxygen in that inhaled air
the visceral pleura. There is normally no space between these is transported across the lining membrane of the alveoli, into
two membranes. In fact, a small amount of fluid between the adjacent small blood vessels known as capillaries, where it
two membranes holds them together, much as a thin layer of attaches to hemoglobin in the red blood cells for transport to
water will hold two sheets of glass together. This pleural fluid the rest of the body. This process is known as oxygenation.
creates a surface tension, which opposes the elastic nature Simultaneously, carbon dioxide, which is dissolved in the
of the lungs, preventing their otherwise natural t endency to blood, diffuses out into the air within the alveoli for expulsion
collapse. when that air is blown out again in the process of exhalation
(Figure 12-3). Cellular respiration is the use of oxygen by the
The lungs occupy the right and left sides of the chest cavity cells to produce energy (see the Physiology of Life and Death
(Figure 12-2). Between them and enveloped by them is a space and the Airway and Ventilation chapters).
called the mediastinum, which contains the trachea, the main
bronchi, the heart, the major arteries and veins to and from the
heart, and the esophagus.

Alveolar CHAPTER 12 Thoracic Trauma 337
epithelium
Inspiration

Pectoralis
minor muscle

contracts
External
intercostal
muscles
contract -r--__.._i~~

Figure 12-3 The capillaries and alveoli lie in close proximity; A Diaphragm contracts

therefore, oxygen (02) can easily diffuse through the capillary,
alveolar walls. capillary walls, and red blood cells. Carbon dioxide

(C02) can diffuse back in the opposite direction.

Expiration

Inhalation is brought about by contraction of the muscles Internal Diaphragm
of respiration (primarily the intercostal muscles and the dia- intercostal relaxes
phragm), which results in a lifting and separating of the ribs
and downward motion of the diaphragm. This action increases muscles Transverse
the size of the thoracic cavity and creates a negative pressure abdominis
within the chest compared with the air pressure outside the contract-~--~•
body. As a result, air flows into the lungs (Figures 12-4 and 12-5).
Diaphragm
Expiration is achieved by relaxing the intercostal muscles and relaxes
diaphragm, resulting in the return of the ribs and diaphragm to
Abdominal
their resting positions. This return causes the pressure within muscles
the chest to exceed the pressure outside the body, and air from contract
the lungs is emptied through the bronchi, trachea, mouth, and
nose to the outside. Rectus

Ventilation is under the control of the respiratory center B abdominis
of the brain stem. The brain stem controls ventilation through
monitoring of the partial pressure of arterial carbon dioxide Figure 12-4 A. During inspiration. the diaphragm contracts and
(PaC02) and partial pressure of arterial oxygen (Pa02) by spe- flattens. Accessory muscles of inspiration-such as the external
cialized cells known as chemoreceptors. Chemoreceptors are intercostal, pectoralis minor, and sternocleidomastoid muscles-lif t
located in the brain stem and in the aorta and carotid arteries. the ribs and sternum, which increases the diameter and volume
If the chemoreceptors detect increased PaCOv they stimulate of the thoracic cavity. B. In expiration during quiet breathing, the
the respiratory center to increase the depth and frequency of elasticity of the thoracic cavity causes t he diaphragm and ribs to
assume their resting positions, w hich decreases t he volume of the
breaths, eliminating more carbon dioxide and returning PaC02 thoracic cavity. In expiration during labored breathing, muscles of
to normal (Figure 12-6). This process is very efficient and can expiration-such as the internal intercostal and abdominal m uscles-
increase the volume of air moved in and out of the lungs per contract. causing t he volume of the thoracic cavity to decrease more
minute by a factor of 10. Mechanoreceptors, found in the air- rapidly.
ways, lungs, and chest wall, measure the degree of stretch in
these structures and provide feedback to the brain stem about
lung volume.

In certain lung diseases, such as emphysema, or chronic
obstructive pulmonary disease (COPD), the lungs are not able
to eliminate carbon dioxide as effectively. This results in a
chronic elevation of the carbon dioxide level in the blood. The

3 3 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 12-5 When the chest cavity expands during inspiration, Figure 12-7 Receptors located in t he aorta and carotid arteries are
the intrathoracic pressure decreases and air goes in t he lungs. sensitive to the oxygen level and wi ll stimulate the lungs to increase
When the diaphragm relaxes and the chest returns to its resti ng air movement into and out of the alveolar sacs.
position, the intrathoracic pressure increases and air is expelled.
When the diaphragm is relaxed and the glottis is open, the pressure values (Figure 12-7). This mechanism is often referred to as
inside and outside the lungs is equal. "hypoxic drive," as it is related to falling levels of oxygen in the
blood.

The concept of the hypoxic drive has led to recommenda-
tions to limit the amount of oxygen given to trauma patients
with pre-existing COPD for fear of suppressing their impetus
to breathe. Trauma patients who are hypoxic should never be
deprived of supplemental oxygen in the prehospital setting.4
The true existence of the hypoxic drive remains controver-
sial. If it truly exists, it will not manifest itself in the acute
setting.

Figure 12-8 defines several terms that are important in dis-
cussing and understanding the physiology of ventilation.5

Circulation

Respiratory The other major physiologic process that may be affected fol-
center lowing thoracic injury is circulation. The Shock chapter covers
this topic more extensively, but the following discussion sets the
Figure 12-6 A n increased level of carbon dioxide is detected by stage for the pathophysiology of chest injury.
nerve cells sensitive to this change, w hich stimulates the lung to
increase both depth and rate of ventilation. The heart, which lies in the center of the chest within the
mediastinum, functions as a biologic pump. For a pump to
chemoreceptors become insensitive to changes in PaC0 • As a work, it must be primed with fluid and the fluid level main-
2 tained. For the heart, this priming function is provided by the
return of blood through two large veins, the superior vena
result, the chemoreceptors in the aorta and carotid arteries stim- cava and the inferior vena cava. The heart then normally con-
ulate breathing when the Pa0 falls. Similar to when the brain tracts 70 to 80 times per minute on average (normal range 60
to 100 beats per minute), ejecting approximately 70 milliliters
2 (ml) of blood with each beat out to the body through
the aorta.
stem chemoreceptors detect an increase in PaC02 and stimulate
increased respirations to lower the carbon dioxide level, the oxy- Processes that interfere with the return of blood to the
gen chemoreceptors send feedback to the respiratory center that heart through the superior and inferior venae cavae (e.g., loss
stimulate the respiratory muscles to be more active, increasing of blood through hemorrhage, increased pressure in the chest
the ventilatory rate and depth to raise the Pa0 to more normal cavity from tension pneumothorax) cause the output ofthe heart
and thus the blood pressure to decrease. Similarly, processes
2

CHAPTER 12 Thoracic Trauma 339

Figure 12-8 airflow through the wound is less than that through the air-
ways. Air in the pleural space (pneumothorax) disrupts the
• Dead space. Amount of air brought into the lungs that adherence between the pleural membranes created by the thin
does not have the opportunity to exchange oxygen film of pleural ft.uid. All these processes together allow the
and carbon dioxide with the blood in the alveolar lung to collapse, preventing effective ventilation. Penetrating
capillaries (e.g., air in trachea and bronchi). wounds result in an open pneumothorax only when the size
of the chest wall defect is large enough that the surrounding
• Minute ventilation (\/). Total volume of air moved tissues do not close the wound at least partially during inspira-
into and out of the lungs in 1 minute. tion and/or expiration.

• Tidal volume (VT). Amount of air that is inhaled then Wounds of the lung caused by a penetrating object allow
exhaled during a normal breath (0.4 to 0.5 liters). air to escape from the lung into the pleural space and result in
collapse of the lung. In either case, the patient becomes short
• Total lung capacity (TLC). Total volume the lungs of breath. To make up for the lost ventilation capacity, the
contain w hen maximally inflated. This volume respiratory center will stimulate more rapid breathing. This
declines with age from 6.0 liters in young adults to increases the work of breathing. The patient may be able to
approximately 4.0 liters in elderly persons. tolerate the increased workload for a time, but if not recog-
nized and treated, the patient is at risk for ventilatory failure,
• Work of breathing. Physical work or effort performed which will be manifested by increasing respirat ory distress
in moving the chest wall and diaphragm to breathe. as the carbon dioxide levels in the blood rise and the oxygen
This work increases with rapid breathing, increasing levels fall.
minute ventilation, and when the lungs are abnormally
stiff. Ifthere is continued entry of air into the chest cavity with-
out any exit, pressure will begin to build within the pleural
that injure the heart itself (e.g., blunt cardiac injury) may make space, leading to tension pneumothorax. This will further
the heart a less efficient pump, causing the same physiologic impede the patient's ability to properly ventilate. It also will
abnormalities. Just as chemoreceptors recognize changes in car- begin to impact circulation negatively as venous return to the
bon dioxide or oxygen levels, baroreceptors located in the arch heart is reduced by the increasing intrathoracic pressure, and
of the aorta and the carotid sinuses of the carotid arteries rec- shock may ensue. In extreme cases with displacement of the
ognize changes in blood pressure and direct the heart to change mediasti nal structures (organs and vessels located in the
the rate and forcefulness of its beating to return the blood pres- middle of the chest between the two lungs) into the opposite
sure to normal. side of the chest, venous return is highly compromised, lead-
ing to decreased blood pressure and jugularvenous distension,
Pathaphysialagy and the classic, but late, finding of tracheal shift away from
the midline toward the uninvolved side of the chest may be
As mentioned earlier, both blunt and penetrating mecha- detected.
nisms may disrupt the physiologic processes just described.
There are common elements in the disturbances created by Laceratedtissues and torn blood vessels bleed. Penetrating
these mechanisms. wounds to the chest may result in bleeding into the pleural
space ( hemothorax) from the chest wall muscles, the inter-
Penetrating Injury costal vessels, and the lungs. Penetrating wounds to the major
vessels in the chest result in catastrophic bleeding. Each pleu-
In penetrating injuries, objects of varying size and type tra- ral space can accommodate approximately 3,000 ml of ft.uid.
verse the chest wall, enter the thoracic cavity, and possibly Thoracic bleeding into the pleural space may not be readily
injure the organs within the thorax. Normally, no space exists apparent externally, but it may be of sufficient magnitude to
between the pleural membranes. However, when a penetrating create a shock state. The presence of large volumes of blood
wound creates a communication between the chest cavity and in the pleural space will also impede the patient's ability to
the outside world, air can enter into the pleural space through
the wound during inspiration when the pressure inside the breathe; the blood in the pleural space prevents expansion
chest is lower than the pressure outside the chest. Air may of the lung on that side. It is not uncommon for an injury to
be further encouraged to enter a wound if the resistance to the lung to result in both a hemothorax and a pneumothorax,
termed a hemopneumothorax. A hemopneumothorax results
in collapse of the lung and impaired ventilation from both the
air in the pleural space and the accumulation of blood in the
thoracic cavity.

Wounds of the lung may also result in bleeding into the
lung tissue itself. This blood floods the alveoli, preventing

3 4 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

them from filling with air. Alveoli filled with blood cannot par- The assessment should also include a determination of vital
ticipate in gas exchange. The more alveoli that are flooded, signs. Placement of a pulse oximeter to assess arterial oxygen
the more the patient's ventilation and oxygenation may be saturation is a useful adjunct in the assessment of the injured
compromised. patient.6•7

Blunt Force Injury • Observation. The patient is observed for pallor of
the skin and sweating, which may indicate the pres-
Blunt force applied to the chest wall is transmitted through the ence ofshock. The patient may also appear apprehen-
chest wall to the thoracic organs, especiallythe lungs. This wave sive. The presence of cyanosis (bluish discoloration
of energy can tear lung tissue, which may result in bleeding of skin, especially around mouth and lips) may be
into the alveoli. In this setting the injury is called a pulmonary evident in advanced hypoxia. The frequency of res-
contusion. A pulmonary contusion is essentially a bruise of the pirations and whether the patient appears t o be hav-
lung. It can be made worse by overaggressive fluid resuscitation. ing trouble breathing (gasping, contractions of the
The impact on oxygenation and ventilation is the same as with accessory muscles of respiration in the neck, nasal
penetrating injury. flaring) should be noted. Is the trachea in the midline,
or deviated to one side or the other? Are the jugular
If the force applied to the lung tissue also tears the veins distended? The chest is examined for contu-
visceral pleura, air may escape from the lung into the pleu- sions, abrasions, lacerations, and whether the chest
ral space, creating a pneumothorax and the potential for a wall expands symmetrically with breathing. Does any
tension pneumothorax, as previously described. Blunt force portion of the chest wall move paradoxically with res-
trauma to the chest can also break ribs, which can then lac- piration? (That is, instead of moving out during inspi-
erate the lung, resulting in pneumothorax as well as hemotho- ration, does it collapse inward, and vice versa during
rax (both caused by bleeding from the broken ribs and from exhalation?) If any wounds are identified, they are
the tom lung and intercostal muscles). Blunt force injury carefully examined to see if they are bubbling air as
typically associated with sudden deceleration incidents may the patient breathes in and out.
cause shearing or rupture of the major blood vessels in the
chest, particularly the aorta, leading to catastrophic hemor- • Auscultation. The entire chest is evaluated. Decreased
rhage. Finally, in some cases, blunt force can disrupt the chest breath sounds on one side compared to the other may
wall, leading to instability of the chest wall and compromise indicate pneumothorax or hemothorax on the exam-
of the changes in intrathoracic pressure, leading to impaired ined side. Pulmonary contusions may result in abnor-
ventilation. mal breath sounds (crackles). Although often difficult
to discern in the field, muffled heart sounds from blood
Assessment collecting around the heart and murmurs from valvu-
lar damage may also be noted on auscultation of the
As in all aspects of medical care, assessment involves taking a heart.
history and performing a physical examination. In trauma sit-
uations, we speak of a SAMPLE history, in which the patient's • Palpation. By gently pressing the chest wall with
symptoms, age and allergies, medications, past history, time hands and fingers, assessment for the presence of
of the last meal, and the events surrounding the injury are tenderness, crepitus (either bony or subcutaneous
elucidated (see the Patient Assessment and Management emphysema), and bony instability of the chest wall
chapter).6 is performed.

Besides the overall mechanism that resulted in injury, • Percussion. This examination technique is difficult to
patients are asked about any symptoms they may be experi- perform in the field because the environment is often
encing if they are conscious and able to communicate. Victims noisy, making evaluation of the percussion note diffi-
of chest trauma will likely be experiencing chest pain, which cult. In addition, there is little additional information to
may be sharp, stabbing, or constricting. Frequently, the pain is be obtained from percussion that will change the pre-
worse with respiratory efforts or movement. The patient may hospital management.
report a sense of being short of breath or being unable to take
in an adequate breath. The patient may feel apprehensive or • Pulse oximetry. This should be performed to assess
lightheaded if shock is developing. It is important to remember the level of oxygen bound to hemoglobin and followed
that the absence of symptoms does not equate to the absence to indicate changes in the patient's condition and
of injury. responses to therapy. The oxygen saturation should be
maintained at 95% or greater.
The nextstep in assessment is the performance ofa physical
examination. There are four components to the physical exam- • Waveform capnography. Whether by sidestream
ination: observation, palpation, percussion, and auscultation. assessment with a nasal probe, by mask, or by in-line
assessment in an intubated patient, capnography
(end-tidal carbon dioxide) is used to assess the level

CHAPTER 12 Thoracic Trauma 341

of carbon dioxide in expired air and is followed Assessment
to indicate changes in the patient's condition and
responses to therapy. In-line sampling measures the Patients with simple rib fractures will most often complain of
end-tidal carbon dioxide directly at the point of sam- chest pain with breathing or movement and difficulty breathing.
pling, whereas sidestream assessment takes a sample They may have labored respirations. Careful palpation of the
of expired air and performs the carbon dioxide deter- chest wall will usually reveal point tenderness directly over the
mination at the monitor location, which is remote site of the rib fracture, and crepitus may be felt as the broken
from the sampling site. ends of the rib grind against each other. The prehospital care
provider assesses vital signs, paying particular attention to the
Repeat determinations of the ventilatory rate during patient ventilatory rate and depth of breathing. Pulse oximetry also
reassessment may be the most important assessment tool in should be performed, as well as capnography if available.1•14•15
recognizing that a patient is deteriorating. As patients become
hypoxic and compromised, an early clue to this change is a grad- Management
ual increase in the ventilatory rate.
Pain reliefis a primary goal in the initial management ofpatients
Assessment and with rib fractures. This may involve reassurance and positioning
Management of of the patient's arms using a sling and swath. It is important to
Specific Injuries reassure and continuously reassess the patient, keeping in mind
the potential for deterioration in ventilation and the develop-
Rib Fractures ment of shock. Establishing intravenous (IV) access should be
considered, depending on the patient's condition and anticipated
Rib fractures are commonly encountered by prehospital care transport time. Administration of IV narcotic analgesics may be
providers and are present in approximately 10% of all trauma appropriate in some situations for advanced units with appropri-
patients. Several factors have been shown to contribute to the ate protocols and medical control. The patient is encouraged to
morbidity and mortality of patients with multiple rib fractures, take deep breaths and cough to preventthe collapse ofthe alveoli
including total number ofribs fractured, the presence ofbilateral (atelectasis) and the potential for pneumonia and other compli-
fractures, and increased age (65 years or older).8 The elderly are cations. Rigid immobilization of the rib cage with tape or straps
especially susceptible to rib fractures, likely due to loss of corti- should be avoided because these interventions predispose to the
cal bone mass (osteoporosis), which allows the ribs to fracture development of atelectasis and pneumonia.1•3 Administration of
after sustaining less kinetic force. Regardless of age, mortality supplemental oxygen and assisting ventilations may be neces-
increases as more ribs are fractured. The mortality rate for a sary to ensure adequate oxygenation.
single rib fracture is 5.SoAi, increasing to 10% in those with five
fractured ribs. The mortality rate is 34% in those with eight rib Flail Chest
fractures.9•10
Flail chest occurs when two or more adjacent ribs are fractured
Despite the ribs being fairly well protected by overlying inmore than oneplace along theirlength. The result is a segment
musculature, rib fractures are a common occurrence in tho- of chest wall that is no longer in continuity with the remainder
racic trauma. The upper ribs are broad, thick, and particularly ofthe chest. When the respiratory muscles contract to raise the
well protected by the shoulder girdle and muscles.1.a Because it ribs up and out and lower the diaphragm, the fl.ail segment par-
requires great energy to fracture the upper ribs, patients with adoxically moves inward in response to the negative pressure
upper rib fractures are at risk for harboring other significant being created within the thoracic cavity (Figure 12-9). Similarly,
injuries, such as traumatic disruption of the aorta. Rib fractures when these muscles relax, the segment may move outward as
occur most often in ribs 4 to 8 laterally, where they are thin and pressure inside the chest increases. This paradoxical motion of
haveless overlyingmusculature. The broken ends ofthe ribs may the fl.ail segment makes ventilation less efficient. The degree of
tear muscle, lung, and blood vessels, with the possibility of an inefficiency is directly related to the size of the flail segment.
associated pulmonary contusion, pneumothorax, or hemotho-
rax. 1•3•11 Underlying pulmonary contusion is the most commonly The significant force necessary to produce such a lesion is
associated injury seen with multiple rib fractures. Compression generally transmitted to the underlying lung, resulting in a pul-
of the lung may rupture the alveoli and lead to pneumothorax, monary contusion. The patient thus may have two mechanisms
as discussed previously. Fracture of the lower ribs11-13 may be to compromise ventilation and gas exchange, the fl.ail segment
associated with injuries of the spleen and liver and may indicate and the underlying pulmonary contusion (which is the big-
the potential for other intra-abdominal injuries. These injuries ger problem when it comes to compromising ventilation). As
may present with signs of blood loss or shock.1•3•11 described earlier, the pulmonary contusion does not allow for
gas exchange in the contused portion of the lung because ofalve-
olar flooding with blood.

3 4 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Efforts to stabilize the fl.ail segment with sandbags or other
means are contraindicated as they may further compromise
chest wall motion and, thus, impair ventilations. 1

Pulmonary Contusion

Figure 12-9 Paradoxical motion. If stability of the chest wall has When lung tissue is lacerated or tom by blunt or penetrating
been lost by ribs fractured in two or more places, as intrathoracic mechanisms, bleeding into the alveolar air spaces can result
pressure decreases during inspiration, the external air pressure forces in pulmonary contusion. As the alveoli fill with blood, gas
the chest wall inward. When intrathoracic pressure increases during exchange is impaired because air cannot enter these alveoli
expiration, the chest wall is forced outward. from the terminal airways. In addition, blood and edema fluid
in the tissue between the alveoli further impede gas exchange
Assessment in the alveoli that are ventilated. Pulmonary contusion is almost
always present in the patient with a fl.ail segment and is a com-
As with a simple rib fracture, assessment offlail chest will reveal mon- and potentially lethal-complication of thoracic injury.3•11
a patient in pain. The pain is typically more severe, however, and Deterioration to the point of respiratory failure may occur over
the patient usually appears to be in distress. The ventilatory rate the first 24 hours after injury.
is elevated, and the patient does not take deep breaths because
of the pain. Hypoxia may be present, as demonstrated by pulse Assessment
oximetry or cyanosis. Paradoxical motion may or may not be evi-
dent or easily recognized. Initially, the intercostal muscles will be Assessment findings of the patient are variable depending on the
in spasm and tend to stabilize the fl.ail segment. As these muscles severity of the contusion (percentage of involved lung). Early
fatigue over time, the paradoxical motion becomes increasingly assessment typically may reveal no respiratory compromise. As
evident. The patient will have tenderness and potentially bony the contusion progresses, the ventilatory rate will increase and
crepitus over the injured segment. The instability of the segment rales may be heard on auscultation. In fact, a rising ventilatory
may also be appreciated on palpation. rate is often the earliest clue that a patient is deteriorating from
a pulmonary contusion. A high index of suspicion is necessary,
Management particularly in the presence of a fl.ail segment.

Management of fl.ail chest is directed toward pain relief, ventila- Management
tory support, and monitoring for deterioration. The ventilatory
rate may be the most important parameter to follow and care- Management is directed toward support of ventilation. The
fully measure. Patients who are developing underlying pulmo- prehospital care provider should repeatedly reassess the ven-
nary contusion and respiratory compromise will demonstrate tilatory rate and any signs of respiratory distress. Continuous
an increase in their ventilatory rate over time. Pulse oximetry, pulse oximetry and capnography, if available, should be utilized.
if available, is also useful to detect hypoxia.7 Oxygen should be Supplemental oxygen should be provided to all patients with sus-
administered to ensure an oxygen saturation of at least 95%. pected pulmonary contusion with a goal of maintaining oxygen
saturation in the normal range. CPAP can be used to improve
Intravenous access may be obtained, except in cases of oxygenation in patients in whom supplemental oxygen alone
extremely short transport times. Narcotic analgesics may be proves to be inadequate for maintaining acceptable oxygen sat-
carefully titrated to provide pain relief. uration levels.16 Support of ventilation with bag-mask device or
endotracheal intubation may be necessary.15
Support of ventilation with bag-mask device assistance,
continuous positive airway pressure (CPAP), or endotracheal In the absence of hypotension (systolic blood pressure less
intubation and positive-pressure ventilation may be necessary than 90 millimeters of mercury [mm Hg]), aggressive IV fluid
(particularly with prolonged transport times) for those patients administration may further increase edema and compromise
who are having difficulty maintaining adequate oxygenation.14 ventilation and oxygenation. Instead, IV fluids should be admin-
istered to maintain normal pulse and blood pressure. Pulmonary
contusion is another example in which fluid resuscitation must be
balanced with the patient's other needs. (See the Shock chapter.)

Pneumothorax

Pneumothorax is present in up to 200A> of severe chest injuries.9
The three types of pneumothorax represent increasing levels of
severity: simple, open, and tension.

CHAPTER 12 Thoracic Trauma 3 4 3

Simple pneumothorax is the presence of air within be prolonged, rendezvous with an advanced life s upport (ALS)
the pleural space. As the amount of air in the pleural space unit should be considered.
increases, the lung on that side collapses (Figure 12-10). Open
pneumothorax ("sucking chest wound") involves a pneumotho- A key point in management is the recognition that a simple
rax associated with a defect in the chest wall that allows air to pneumothorax may quickly evolve int o a tension pneumothorax.
enter and exit the pleural space from the outside with ventila- The patient needs to be continuously monitored for development
tory effort. Tension pneumothorax occurs when air continues to of tension pneumothorax so that timely intervention can occur
enter and is trapped in the pleural space with gradual increase before there is a serious compromise of circulation.
in intrathoracic pressure. This leads to shift of the mediastinum
and results in decreased venous blood return to the heart and Open Pneumothorax
compromised circulatory function.
Open pneumothorax, as with simple pneumothorax, involves air
Simple Pneumothorax entering the pleural space, causing the lung to collapse. A defect
in the chest wall that results in a communication between the
Assessment outside air and the pleural space is the hallmark ofan open pneu-
mothorax. Mechanisms leading to open pneumothorax include
Assessment in simple pneumothorax is likely to demonstrate gunshot wounds, shotgun blasts, stabbings, impalements, and
findings similar to those in rib fracture. The patient frequently rarely blunt trauma. When the patient attempts to inhale, air
complains of pleuritic chest pain (pain while breathing) and crosses the open wound and enters the pleural space because
shortness of breath that may vary from mild to severe, and may of the negative pressure created in the thoracic cavity as the
exhibit varying symptoms and signs of respiratory dysfunction. muscles of respiration contract. In larger wounds, there may be
The classic findings are decreased breath sounds on the side free flow of air in and out of the pleural space with the different
of injury. Any patient with respiratory distress and diminished phases of respiration (Figure 12-11). Audible noise is often cre-
breath sounds should be assumed to have a pneumothorax. ated as air travels in and out of the hole in the chest wall; thus,
this wound has been referred to as a "sucking chest wound."
Management
Because airflow follows the path of least resistance, this
The prehospital care provider administers supplemental abnormal airflow through the chest wall may occur preferentially
oxygen, obtains IV access, and prepares to treat shock if it to the normal flow through the upper airway and trachea into the
develops. Monitoring of pulse oximetry and waveform cap- lung, especially ifthe open defect is similar or larger in size than
nography, if available, is essential to expectant management of the glottic opening to the lower airway. Resistance to the flow
the patient in order to detect early signs of respiratory dete- of air through a wound decreases as the defect size increases.
rioration.9·13·17·18 If spinal immobilization is not necessary, the Effective ventilation is then inhibited both by the collapse of
patient may be more comfortable in a semi-recumbent position. the lung on the injured side and with the preferential flow of air
Rapid transport is essential.13•15•17 If the prehospital care pro- into the pleural space through the wound rather than via the tra-
vider is functioning at the basic level and transport time will chea into the alveoli of the lung. Though the patient is breathing,
oxygen is prevented from entering the circulatory system.

Potential
space

Air in pleural Chest wall
space
Parietal
Visceral pleura
pleura

Figure 12-10 Air in the pleural space forces the lung in, decreasing Figure 12-11 A gunshot or stab w ound to t he chest produces a
the amount that can be ventilated and, therefore, decreasing hole in the chest wall through wh ich air can flow both into and out
oxygenation of the blood leaving the lung. of the pleural cavity.

Source: Courtesy Norman Mcswain, MD, FACS, NREMT-P.

3 4 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Assessment

Assessment of the patient with open pneumothorax generally
reveals obvious respiratory distress. The patient will typically be
anxious and tachypneic (breathing rapidly). The pulse rate will
be elevated and potentially thready. Examination of the chest
wall will reveal the wound, which may make audible sucking
sounds during inspiration, with bubbling during expiration.

Management Figure 12-13 Vented chest seals have been shown in animal
studies to prevent the development of tension pneumothorax after
Initial management of an open pneumothorax involves sealing sealing of an open chest wound .
the defect in the chest wall and administering supplemental
oxygen. Airflow through the wound into the pleural cavity is Source: Courtesy of H & H Medical Corporation.
prevented by applying an occlusive dressing using commercial
products such as the Halo, Asherman, or Bolin chest seals or those cases sealed with a vented dressing.19 This study showed
improvised methods such as application of aluminum foil or that both seals improved the respiratory physiology associated
plastic wrap; unlike plain gauze, these materials do not allow air- with an open pneumothorax; however, the vented seal prevented
flow through them. the development of tension pneumothorax, which the unvented
seal did not. This finding has led the military's Committee on
A patient with an open pneumothorax virtually always has Tactical Combat Casualty Care to recommend that, if available,
an injury to the underlying lung, allowing for two sources of air a vented chest seal is preferred over an unvented chest seal.20 An
leak, the first being the hole in the chest wall and the second unvented chest seal is an acceptable alternative ifthe vented type
being the hole in the lung. Even if an injury to the chest wall is is not available; however, the patient must be carefully observed
sealed with an occlusive dressing, air leakage into the pleural for the subsequent development of a tension pneumothorax.
space can continue from the injured lung, setting the stage for
the development of a tension pneumothorax (Figure 12-12). In view of the research, Prehospital Trauma Life Support
now recommends the following approach to the management of
The traditional teaching has been that for an open pneumo- an open pneumothorax:
thorax, the occlusive dressing is secured on three sides.1 This
prevents airflow into the chest cavity during inspiration while
allowing air to escape through the loose side of the dressing
during exhalation and hopefully preventing the development
of a tension pneumothorax (Figure 12-13). In contrast, taping
the occlusive dressing on all four sides has been advocated as
preferable to taping only on three sides; however, no definitive
answer to this issue has been determined.

Arecentstudyin animals comparedthe physiologicresponse
of an open pneumothorax that has been completely sealed with
a commercial unvented occlusive dressing to the response in

Visceral pleura • Place a vented chest seal over the open chest wound.
• If a vented seal is not available, place a plastic or foil
Chest wall injury
square over the wound and tape on three sides.
Air in pleural --t'----+--f- • If none of the above are available, an unvented chest

space seal or a material such as petroleum gauze that pre-
Partially collapsed vents ingress and egress of air may be used; however,
this approach may allow the development of tension
lung pneumothorax, so the patient must be observed care-
fully for signs of deterioration.
Figure 12-12 Because of the proximity of the chest wall to the • Ifthe patient develops tachycardia, tachypnea, or other
lung, it would be extremely difficult for the chest wall to be injured indications of respiratory distress, remove the dressing
by penetrating trauma and the lung not to be injured. Stopping the for a few seconds and assist ventilations as necessary.
hole in the chest wall does not necessarily decrease air leakage into • If respiratory distress continues, assume the develop-
the pleural space; leakage can come from the lung just as easi ly. ment of a tension pneumothorax and perform a nee-
dle thoracostomy using a large-bore (10- to 16--gauge)

CHAPTER 12 Thoracic Trauma 3 4 5

needle that is 3.5 inches (8 cm) in length in the second venousreturn to the heartthroughthe kinking ofthe inferiorvena
intercostal space in the midclavicular line or at the nip- cava as it passes through the diaphragm. Additionally, inflation
ple line in the midaxillacy line. of the lung on the unirtjured side is increasingly restricted, and
further respiratory compromise results.
If these measures fail to support the patient adequately,
endotracheal intubation and positive-pressure ventilation may Any patient with thoracic injury is at risk for development of
be necessary.14 If positive pressure is utilized and a dressing has tension pneumothorax. Patients at particular risk are those who
been applied to seal the open wound, the prehospital care pro- likely have a pneumothorax (e.g., patient with signs of rib frac-
vider needs to monitor the patient carefully for the development ture), those who have a known pneumothorax (e.g., patient with
of tension pneumothorax. If signs of increasing respiratory dis- a penetrating wound to the chest), and those with chest irtjury
tress develop, the dressing over the wound should be removed to who are undergoing positive-pressure ventilation. Such patients
allow for decompression of any accumulating tension. If this is must be continuously monitored for signs of increasing respira-
ineffective, needle decompression and positive-pressure ventila- tory distress associated with circulatory impairment and rapidly
tion should be considered, if not already employed.21 transported to an appropriate facility.

In those cases in which positive-pressure ventilation is Assessment
being performed, the wound does not need to be sealed. The
positive-pressure ventilation effectively manages the pathophys- The findings during assessment depend on how much pressure
iology usually associated with the open pneumothorax by venti- has accumulated in the pleural space (Figure 12-15). Initially,
lating the lung directly. patients will exhibit apprehension and discomfort. They will
generally complain of chest pain and difficulty breathing. As the
Tension Pneumothorax tension pneumothorax worsens, they will exhibit increasing agi-
tation, tachypnea, and respiratory distress. In severe cases, cya-
Tension pneumothorax is a life-threatening emergency. As air nosis and apnea may occur.
continues to enter the pleural space without any exit or release,
intrathoracic pressure builds up. As intrathoracic pressure rises, The classic findings are tracheal deviation away from the
ventilatory compromise increases and venous return to the heart side of irtjury, diminished breath sounds on the side of injury, and
decreases. The decreasing cardiac output coupled with wors- a tympanitic percussion note. It is difficult to detect diminished
ening gas exchange results in profound shock. The increasing breath sounds in the field environment. Constant practice with
pressure on the irtjured side ofthe chest may eventuallypush the auscultation of all patients will hone the prehospital care pro-
structures in the mediastinum toward the other side ofthe chest vider's skill and make detection of this important finding more
(Figure 12-14). This distortion of anatomy may further impede likely. Detection of a tympanitic percussion note in the field is
basically impossible, but the finding is mentioned for the sake of
completeness. Transport and treatment should never be delayed
for purposes ofperforming percussion ofthe chest.

Other physical findings that may be evident are jugular
venous distension, chest wall crepitus, and cyanosis. Tachycardia
and tachypnea become increasingly prominent as the intratho-
racic pressure builds and the pulse pressure narrows, culminat-
ing in hypotension and uncompensated shock.

Management

The priority in management involves decompressing the tension
pneumothorax.14 Decompression should be performed when the
following three findings are present:

1. Worsening respiratory distress or difficulty ventilating
with a bag-mask device

2. Unilateral decreased or absent breath sounds
3. Decompensated shock (systolic blood pressure less

than 90 mm Hg with a narrowed pulse pressure)14-18,21

Figure 12-14 Tension pneumothorax. If the amou nt of air trapped Depending upon the clinical setting and the training level
in the pleural space continues to increase, not only is the lung on of the prehospital care provider, several options (discussed
the affected side collapsed, but the mediastinum is shifted to the below) for pleural decompression exist. If decompression is not
opposite side. The lung on the opposite side is then compressed an option (i.e., only basic life support [BLS] available and no
and intrathoracic pressure increases, which kinks the vena cava and occlusive dressing to remove), rapid transport to an appropriate
decreases blood return to the heart. facility while administering high-concentration oxygen (fraction
of inspired oxygen [Fi02) ~ 85%) is imperative. Positive-pressure

3 4 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 12-15

Although the following signs are frequently discussed with and sometimes can involve the abdominal wall and face
a tension pneumothorax, many may not be present or are as well.
difficult to identify in the field. • Tracheal deviation is usually a late sign . Even when it
is present, it can be difficult to diagnose by physical
Observation examination. In the neck, the trachea is bound to
• Cyanosis may be difficult to see in the field. Poor lighting, the cervical spine by fascial and other supporting
structures; thus, the deviation of the trachea is more
variation in skin color, and dirt and blood associated with of an intrathoracic phenomenon, although deviation
trauma often render this sign unreliable. may be palpated in the jugular notch if it is severe.
• Distended neck veins are described as a classic sign of Tracheal deviation is not often noted in the prehospital
tension pneumothorax. However, since a patient with a environment.
tension pneumothorax may also have lost a considerable
amount of blood, distended neck veins may not be Auscultation
prominent. • Decreased breath sounds on the injured side. The most

Palpation helpful part of the physical examination is checking
• Subcutaneous emphysema is a common finding. As the for decreased breath sounds on the side of the injury.
However, to use this sign, the prehospital care provider
pressure builds up within the chest cavity, air will begin must be able to distinguish between normal and
to dissect through the tissues of the chest wall. Because decreased sounds. Such differentiation requires a great
tension pneumothorax involves significantly elevated deal of practice. Listening to breath sounds during every
intrathoracic pressure, the subcutaneous emphysema can patient contact will help.
often be palpated across the entire chest wall and neck

ventilatory assistance should be used only if the patient is animal model.22 The immediate improvement in oxygenation and
hypoxic and fails to respond to supplemental oxygen, as this sit- in ease of ventilation may be lifesaving.
uation may rapidly worsen the tension pneumothorax. Assisting
ventilations may result in air accumulating more rapidly in If a patient with suspected tension pneumothorax was previ-
the pleural space. If ALS intercept is an option, it should be ously intubated, the position ofthe endotracheal (ET) tube should
accomplished if the intercept will be faster than delivery to an be assessed and confirmed prior to performing needle decompres-
appropriate facility. sion. If the ET tube has slipped farther down from the trachea
into one of the main bronchi (usually the right), the opposite lung
Removal of an Occlusive Dressing will not be ventilated and breath sounds and chest wall expansion
may be markedly diminished. In these cases, repositioning of the
In the patient with an open pneumothorax, ifan occluding dress- ET tube is warranted prior to considering needle decompression.
ing has been applied, it should be briefly opened or removed.
This should allow the tension pneumothorax to decompress Needle decompression is typically performed through the
through the wound with a rush of air. This procedure may need second or third intercostal space in the midclavicular line of the
to be repeated periodically during transport if symptoms of ten- involved side of the chest (Figure 12-16). This location is cho-
sion pneumothorax recur. If removing the dress ing for several sen because of ease of access for the prehospital care provider
secon ds is ineffective or if there is no open wound, an ALS pro- transporting a patient who likely has been "packaged for trans-
vider may proceed with a needle thoracostomy. port" on a backboard with cervical collar, with arms down along
the sides (making access difficult to the midaxillary line, where
Needle Decompression (Needle Thoracostomy) chest tubes are usually placed). Once placed in this location, the
catheter is less likely to be displaced from the chest wall during
Insertion of a needle into the pleural space of the affected side patient movement. The lung on the affected side is collapsed and
permits accumulated air, under pressure, to escape. While stud- shifted toward the contralateral side; therefore, it is unlikely to
ies in human patients have primarily been anecdotal reports, be injured during the procedure. The needle and catheter should
needle decompression has been shown to be effective in an be advanced until the return of a rush of air is achieved and
advanced no farther. Once the decompression is achieved, the

CHAPTER 12 Thoracic Trauma 3 4 7

- - - - - Midclavicular line Regardless of the method chosen, decompression should be
performed with a large-bore (10- to 16--gauge) IV needle that is
Second at least 8 cm (3.5 inches) in length. Careful monitoring of the
in te rcosta l patient following the procedure is mandatory. A recent review
space noted a 26% mechanical failure rate due to kinking, obstruc-
tion, or dislodgement, with 43% of attempts ultimately failing to
Figure 12-16 Needle decompression of the thoracic cavity is most relieve the tension pneumothorax.29
easily accomplished and produces the least chance for complication
if it is done at the midclavicular li ne through the second intercostal This procedure, when successfully performed, converts
space. the tension pneumothorax into a negligible open pneumotho-
Source: Background image© Mariya L/ShutterStock. rax. The relief to respiratory effort far outweighs the negative
effect of the open pneumothorax. Because the diameter of the
catheter is taped to the chest to prevent dislodgement. Improper decompression catheter is significantly smaller than the patient's
placement (location or depth) may result in injuries to the lungs, airway, it is unlikely that any air movement through the catheter
heart, or great vessels.23 will significantly compromise ventilatory effort. Thus, creation of
a one-way valve (Heimlich valve) is probably unnecessary from
Several recent studies have questioned this location for a clinical standpoint. Using a manufactured valve is costly, and
placement, noting that chest wall thiclmess in the midclavicular fashioning a valve from a glove is time consuming. Continued
line is often greater than the length of the catheter commonly provision ofsupplemental oxygen, as well as ventilatory support
used for decompression. Recent evidence suggests that place- as needed, is appropriate.
ment of the catheter in the fifth intercostal space of the anterior
or middle axillary line could provide greater success. A study As a general rule, bilateral tension pneumothorax is exceed-
using computed t omography (CT) scan to review chest wall ingly rare in patients who are not intubated and ventilated with
thiclmess of trauma patients noted an average chest wall thick- positive pressure. The first step in reassessing the patient is to
ness in the midclavicular line to be 46 mm (right) and 45 mm confirm the location of the ET tube, ensure that it has no kinks
(left). In the same patients, the average chest wall thiclmess was or bends causing compression of the tube, and ensure that the
33 mm (right) and 32 mm (left) in the anterior axillary line. The tube has not inadvertently moved down into a main bronchus.
study's authors noted that needle decompression using a stan- Extreme caution should be exercised with bilateral needle
dard 5-cm needle would fail in 42.5% ofcases in the midclavicular decompression in patients who are not being ventilated with
line versus only 16.7% in the anterior axillary line.24 The authors positive-pressure ventilation. If the prehospital care provider's
also noted in a cadaveric study that needle decompression in the assessment is in error, the creation of bilateral pneumothoraces
fifth intercostal space, midaxillary line resulted in 100% success- can cause severe respiratory distress.
ful placement into the thoracic cavity compared to only 57.5% in
the midclavicular line.25 The patient should be rapidly transported to an appropriate
facility. Intravenous access should be obtained unless transport
Each location has clear advantages and disadvantages. time is particularly short. The patient must be closely observed
Decompression in the midclavicular line has the advantage of for deterioration. Repeat decompression and endotracheal intu-
ease ofaccess for the prehospital care provider and lower chance bation may become necessary.
of dislodgement or kinking during patient movement. However,
there is a risk of inducing major hemorrhage from inadvertent Tube Thoracostomy (Chest Tube Insertion)
placement of the catheter into the subclavian vessels (superi-
orly) or internal mammary artery, heart, or pulmonary vessels In general, insertion of a chest tube (tube thoracostomy)
(medially).26•27 Additionally as noted earlier, chest wall thiclmess is not performed in the prehospital setting because of con-
often results in the catheter never actually entering the thoracic cerns of time, procedural complications, infection, and train-
cavity. Advantages of the midaxillary placement of the catheter ing issues. Needle decompression can be accomplished in a
include its relative safety and efficacy. Recent data from the mil- fraction of the time required to perform a tube thoracostomy
itary does suggest a higher rate of catheter kinking and failure because fewer steps are necessary and less equipment is used.
when placed in the midaxillary line, primarily due to movement Published complication rates with tube thoracostomy range
of the patient.28 from 2.8% to 21%,30•31 and include damage to the heart or lungs
and malposition in the subcutaneous tissues of the chest wall
or in the peritoneal cavity. This procedure requires a sterile
field, which is challenging to create in the field. A break in
sterile technique, such as contamination of the chest tube or
instruments may result in the development of an empyema
(collection of pus in the pleural space), requiring surgical
intervention and drainage. Significant training is required to
develop this skill, and ongoing practice is required to maintain
skill proficiency.

3 4 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Patients being transported with a chest tube in place are still tubing. Next, ensure that the connecting tubing is correctly
at risk for the development of a tension pneumothorax, partic- connectedto a waterseal and drainage device. Evenwith no iden-
ularly if they are undergoing positive-pressure ventilatory assis- tified problems, the patient with signs of an increasing tension
tance. If signs of a tension pneumothorax begin to manifest, first pneumothorax may require needle decompression. Do not delay
ensure that there are no kinks in the chest tube or connecting just because there is already a chest tube in place (Figure 12-17).

Figure 12-17

Three Basic Components of Chest Tube Drainage Troubleshooting Steps
Systems • Assess the dressing and tube site to ensure that the chest
1. Seal. Allows air to escape pleural space but not return.
tube has not been dislodged during transfers.
The seal is generally a water seal that bubbles as air • Check that the chest tubing is all tightly connected and
escapes the pleural space and rises with inspiratory
negative pressure. unobstructed, with no kinks or clamps.
2. Collecting system. Collects and measures • Check that the chest seal is intact and functioning. Is
output. Observe for changes in volume of output
and nature. there any bubbling and/or variation with ventilations?
3. Suction. Provides negative pressure to assist • Assess whether the chest tube is fogging and/or drainage
drainage and expansion. Ensure that suction is
appropriately attached and functioning. Review the is continuing.
basic operation of any drainage system with • Ensure that the suction is functioning. Is there continuous
the patient's health care team prior to transfer of
the patient. bubbling or a negative pressure indicator throughout the
ventilation cycle?
Changes in Respiratory Status in Patients with • If the patient's ventilatory status continues to
Chest Tubes deteriorate, assess closely for signs of developing
• Assess vital signs, including pulse oximetry. tension pneumothorax. If indicated, disconnect the
chest tube from the drainage system, which should
If the chest tube is not working properly, the allow release of tension if the chest tube is properly
patient may become tachycardic, tachypneic, and placed and unobstructed. If this step does not relieve the
hypoxic. If tension pneumothorax is developing, condition, consider needle decompression and contact
subcutaneous emphysema, increasing respiratory online medical control.
distress, narrowing pulse pressure, and hypotension
may result. From patient
• Assess lung sounds. The lung sounds may become
diminished in the involved side if the chest is no longer Collection Water seal
functioning and instead is allowing air to reaccumulate chamber
within the chest.
• Assess ventilatory effort. Ventilatory effort will increase
when the chest tube is not functioning .
• Assess circulation. If the chest tube is not
working properly and is allowing air to
accumulate within the chest, the patient may
become tachycardic. If tension pneumothorax
is developing, narrowing pulse pressure and
hypotension may result.
• Assess level of consciousness. If hypoxia or signs of shock
develop, the patient may become agitated and anxious.
As these complications progress, the patient's level of
consciousness will decrease.

CHAPTER 12 Thoracic Trauma 3 4 9

Hemothorax supported if necessary with bag-mask device or endotracheal
intubation if available and indicat ed. Hemodynamic status
Hemothorax occurs when blood enters the pleural space. is closely monitored. Intravenous access should be obtained
Because this space can accommodate a large volume of blood and appropriate fluid therapy provided with a goal of main-
(2,500 to 3,000 ml), hemothorax can represent a source ofsignifi- taining adequate perfusion without large volumes indis-
cant blood loss. In fact, the loss ofcirculating blood volume from criminately administered. Rapid transport to an appropriate
bleeding into the pleural space represents a greater physiologic facility capable of immediate blood transfusion and surgi-
insult to the patient with chest injury than the collapse of the cal intervention completes the management algorithm for
lung that the hemothorax produces (Figure 12-18). It is rare that hemothorax.
enough blood accumulates to create a "tension hemothorax."
The mechanisms resulting in hemothorax are the same as those Blunt Cardiac Injury
causing the various types of pneumothorax. The bleeding may
come from the chest wall musculature, intercostal vessels, lung Cardiac injury most often results from application of force to
parenchyma, pulmonary vessels, or great vessels ofthe chest. the anterior chest, especially in a deceleration event such as a
motor vehicle crash with violent frontal impact. 1•2•32 The heart
Assessment is then compressed between the sternum anteriorly and the
spinal column posteriorly (Figure 12-19). This compression
Assessment reveals a patient in some distress, depending upon of the heart causes an abrupt increase in the pressure within
the degree of blood lost into the chest and compression of the the ventricles to several times normal, which results in car-
lung on the involved side. Chest pain and shortness of breath diac contusion, sometimes valvular injury, and rarely cardiac
are again prominent features, generally with signs of significant rupture, as follows:
shock. The prehospital care provider monitors the patient for
signs of shock: tachycardia, tachypnea, confusion, pallor, and • Cardiac contusion. The most common result of car-
hypotension. Breath sounds on the side of the injury are dimin- diac compression is cardiac contusion. The heart
ished or absent, but the percussion note is dull (compared to muscle is bruised, with varying amounts of injury to
tympanitic for a pneumothorax). Pneumothorax may be present the myocardial cells. This injury most often results in
in conjunction with hemothorax, increasing the likelihood for abnormal heart rhythms, such as sinus tachycardia.32
cardiorespiratory compromise. Because of loss of circulating Of greater concern, but less common, are premature
blood volume, distended neck veins often are not present. ventricular contractions or nonperfusing rhythms
such as ventricular tachycardia and ventricular fibril-
Management lation. If the septal region of the heart is injured,
the electrocardiogram (ECG) may demonstrate
Management includes constant observation to detect physio- intraventricular conduction abnormalities, such as
logic deterioration while providing appropriate support. High-
concentration oxygen should be administered and ventilation

Partially
collapsed

lung

Parietal
pleura

Visceral

pleura - r - - --1.....

Blood in pleural
space

Figure 12-18 Hemothorax. The amount of blood that can Figure 12-19 The heart can be compressed between the sternum
accumulate in the thoracic cavity (leading to hypovolemia) is a much (as the sternum stops against t he steering column or dashboard) and
more severe condition than the amount of lung compressed by this the posterior thoracic wall (as t he wall continues its forward motion).
blood loss. This compression can contuse t he myocardium.

3 5 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

right bundle branch block. If a sufficient volume of cardiac injury. As always, ventilatory support measures should
myocardium is injured, the contractility of the heart be implemented as indicated.
may be impaired, and cardiac output falls, resulting in
cardiogenic shock. Unlike the ot her forms of shock Cardiac Tamponade
usually encountered in the trauma setting, this shock
does not improve with fluid administration and may Cardiac tamponade occurs when a wound of the heart allows
actually worsen. fluid (usually blood) to acutely accumulate between the peri-
cardial sac and the heart.1•32 The pericardial sac is comprised
• Valvular rupture. Rupture of the supporting struc- of a fibrous, inelastic tissue. Normally, there is a small amount
tures of the heart valves or the valves themselves of fluid in the pericardial sac, similar to the pleural space, as
typically renders the valves incompetent. The patient described earlier. Because the pericardium is inelastic, pres-
will present in varying degrees of shock with symp- sure begins to rise rapidly within the pericardial sac as fluid
toms and signs of congestive heart failure (CHF), accumulates within it. This rising pericardial pressure impedes
such as tachypnea, rales, and new-onset heart venous return to the heart. This, in tum, leads to diminished
murmur. cardiac output and blood pressure. With each contraction of
• Blunt cardiac rupture. A rare event, blunt cardiac rup- the heart, additional blood may enter the pericardial sac, fur-
ther impeding the heart's ability to fill in preparation for the
ture occurs in less than 1% of patients with blunt chest next contraction (Figure 12-20). This condition can become
trauma.32-34 Most of these patients will die at the scene profound enough to precipitate pulseless electrical activity,
from exsanguination into the chest or fatal cardiac a life-threatening injury requiring coordinated response by
tamponade. The surviving patients will typically pres- prehospital care providers in all phases of care to achieve an
ent with cardiac tamponade. optimal outcome. The normal adult pericardium may be able
to accommodate as much as 300 ml of fluid before pulseless-
Assessment ness occurs, but as little as 50 ml is usually enough to impede
cardiac return and, thus, cardiac output.1
Assessment of the patient with the potential for blunt cardiac
injury reveals a mechanism that imparted a frontal impact Most often, cardiac tamponade is caused by a stab wound
to the center of the patient's chest. A bent steering column to the heart. This mechanism of injury may result in penetra-
accompanied by bruising over the sternum implies such a tion into one of the cardiac chambers orjust a laceration of the
mechanism. As with other chest injuries, the patient is likely myocardium. The right ventricle is the most anterior chamber
to complain of chest pain and/or shortness of breath. If a in the heart and is therefore the most commonly injured cham-
dysrhythmia is present, the patient may complain of palpita- ber in penetrating trauma. Regardless of the anatomic location
tions. Physical findings of concern are bruising over the ster- of injury, bleeding into the pericardial sac occurs. The rising
num, crepitus over the sternum, and sternal instability. With pressure within the pericardium results in the cardiac tam-
a floating sternum (flail sternum), the ribs on either side of ponade physiology. At the same time, the increased pressure
the sternum are broken, allowing it to move paradoxically with within the pericardium may also temporarily impede further
respirations, similar to fl.ail chest, as described earlier. Ifvalvu- bleeding from the cardiac wound, allowing the patient to sur-
lar disruption h as occurred, a harsh murmur may be detectable vive long enough to reach definitive medical care. In the case
over the precordium along with signs of acute CHF, such as of gunshot wounds to the heart, the damage to the heart and
hypotension, jugular venous distension, and abnormal breath
sounds. ECG monitoring may demonstrate tachycardia, pre-
mature ventricular contractions, other rhythm disturbances,
or ST-segment elevation.

Management Pericardia!
sac
The key management strategy is correct assessment that blunt
cardiac injury may have occurred and transmission of that con- Figure 12-20 Cardiac tamponade. As blood courses from the
cern along with the clinical findings to the receiving hospital. In cardiac lumen into the pericardia! space, it limits expansion of t he
the meantime, high-concentration oxygen is administered and ventricle. Therefore, the vent ricle cannot fill completely. As more
IV access established for judicious fluid therapy. The patient blood accumulates in the pericardia! space, less ventricular space is
should be placed on a cardiac monitor to detect dysrhyth- available to accumulate blood, and cardiac output is reduced.
mias and ST-segment elevations, if present. If dysrhythmias
are present and ALS providers are present, standard antidys-
rhythmic pharrnacotherapy should be instituted. There are no
data to support prophylactic antidysrhythmic therapy in blunt

CHAPTER 12 Thoracic Trauma 351

pericardium is usually so severe that the pericardium cannot Figure 12-22
contain the hemorrhage, resulting in rapid exsanguination into
the chest cavity. The same is true in the case of impalements. The paradoxical pulse, also known as pulsus
Blunt rupture of a cardiac chamber can result in cardiac tam- paradoxus, is actually an accentuation of the normal,
ponade but more often causes exsanguinating hemorrhage. slight drop in systolic blood pressure (SBP) that occurs
during inspiration. As the lungs expand, there is
Cardiac tamponade should be kept in mind as a possibil- preferential filling and ejection of blood from the right
ity when evaluating any patient with a thoracic penetration. side of the heart at the expense of the left side. Thus,
This index of suspicion should be raised to the level of "present peripheral blood pressure falls. This decrease in SBP is
until proven otherwise" when the penetrating injury is within a usually less than 1Oto 15 mm Hg. A greater decrease in
rectangle (the cardiac box) formed by drawing a horizontal line SBP constitutes the so-called paradoxical pulse.
along the clavicles, vertical lines from the nipples to the costal
margins, and a second horizontal line connecting the points of location of the wounds and hypotension, and implement therapy
intersection between the vertical lines and the costal margin accordingly.
(Figure 12-21). The presence ofsuch a wound should be commu-
nicated to the receiving institution as soon as it is recognized to
allow for appropriate preparation to manage the patient.

Assessment

Assessment involves quickly recognizing the presence of at-risk Management
wounds, as previously described, in combination with an appre-
ciation for the physical findings ofpericardia! tamponade. Beck's Management requires rapid, monitored transport to a facility
triad is a constellation of findings indicative of cardiac tampon- that can perform immediate surgical repair.13•16•3741 The prehospi-
ade: (1) distant or muffled heart sounds (the fluid around the tal care provider first needs to recognize that cardiac tamponade
heart makes it difficult to hear the sounds of the valves closing); likely exists and to inform the receiving facility so that prepara-
(2) jugular venous distension (caused by the increasing pressure tions can be made for emergent surgical intervention. Oxygen in
in the pericardia! sac backing blood up into the neck veins); and high concentration should be administered. Intravenous access
(3) low blood pressure. Another physical finding described in should be obtained and judicious fluid therapy initiated, because
cardiac tamponade is paradoxical pulse (Figure 12-22). this can augment central venous pressure and, thus, improve
cardiac filling for a time. The prehospital care provider should
Detection ofsome ofthese signs is difficult in the field, espe- strongly consider endotracheal intubation and positive-pressure
cially muffled heart tones and paradoxical pulse. Additionally, ventilation ifthe patient is hypotensive.18•39•40
the components of Beck's triad are present in only 22% to 77%
of cases of tamponade.35•36 Thus, the prehospital care provider Definitive therapy requires release of the tamponade and
needs to maintain a high index of suspicion, based on the repair of the cardiac injury. A patient with a suspected cardiac
tamponade should be transported directly to a facility capable
of immediate surgical intervention, if available. Draining some
of the pericardia! fluid by pericardiocentesis (insertion of a
needle into the pericardia! space) is often an effective tempo-
rizing maneuver. Risks of pericardiocentesis include injury to
the heart and coronary arteries, resulting in increased tampon-
ade and injury to the lung, great vessels, and liver. In very rare
cases, resuscitative thoracotomy (opening the chest to control
bleeding and repair internal wounds) has been performed in
the field by physicians in systems in which they respond to field
e me r ge ncies. 42•43

Figure 12-21 In a series of 46 patients with penetrating cardiac Commotio Cordis
injuries, 40 had a wound with in the "cardiac box."
The term commotio cordis refers to the clinical situation in
Source: Background image© Mariya L/ShutterStock. which an apparently innocuous blow to the anterior chest
results in sudden cardiac arrest.44•45 Commotio cordis is believed
to account for about 20 deaths per year in the United States,
predominantly in children and adolescents (mean age about
13 years). Most experts theorize that commotio cordis results
from a relatively minor, nonpenetrating blow to the precordium

3 5 2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

(area over the heart), occurring at an electrically vulnerable por- are relatively mobile within the chest cavity. As the arch of the
tion of the cardiac cycle, whereas some believe that coronary aorta transitions to the descending aorta, it is "wrapped" with
artery vasospasm may play a role in its development. Regardless an investing layer of tissue and becomes adherent to the verte-
of the mechanism, the terminal result is a cardiac dysrhythmia bral column. Thus, the descending aorta is relatively immobile.
resulting in ventricular fibrillation and sudden cardiac arrest. When there is a sudden deceleration of the body, such as occurs
in a high-speed frontal impact, the heart and the aortic arch con-
This condition most frequently occurs during amateur sport- tinue to move forward relative to the fixed (immobile) descend-
ing events in which the victim is struck in the midanterior chest ing aorta. This contrast in velocity produces shear forces in the
by a projectile or object, such as a baseball (most common), aortic wall at the junction between these two segments of the
ice hockey puck, lacrosse ball, or softball. However, commotio aorta.40 Thus, the typical location for a traumatic aortic injury
cordis has also been reported after bodily impacts (e.g., karate is just distal to the takeoff of the left subclavian artery. This
blows), a low-velocity motor vehicle crash, and the collision of shear force can disrupt the wall of the aorta in varying degrees
two outfielders trying to catch a baseball. After the impact, vic- (Figure 12-23). When the tear extends through the full thickness
tims have been known to walk a step or two and then suddenly of the aortic wall, the patient rapidly exsanguinates into the pleu-
drop to the ground in cardiac arrest. 1YPically, no injury is noted ral cavity. However, if the tear is only partially through the wall,
to the ribs, sternum, or heart at autopsy. Most victims have no leaving the outer layer (adventitia) intact, the patient may sur-
known history of heart disease. The condition may be prevented vive for a variable length of time, making rapid identification and
through the use of equipment such as safety baseballs.46 treatment essential for a successful outcome.48

Assessment Assessment

Patients who have sustained commotio cordis are found in car- Assessment of aortic disruption hinges on index of suspicion.
diopulmonary arrest. In some victims, a minor bruise is noted A high index should be maintained in situations involving
over the sternum. Ventricular fibrillation is the most common high-energy deceleration/acceleration mechanisms. For such a
rhythm, although complete heart block and left bundle branch devastating injury, there may be little external evidence of chest
block with ST-segment elevations have also been seen. injury. The prehospital care provider needs to assess the ade-
quacy of the airway and breathing and should perform careful
Management auscultation and palpation. Careful examination may demon-
strate that the pulse quality may be different between the two
Once cardiac arrest is confirmed, cardiopulmonary resuscita- upper extremities (pulse stronger in the right arm than the left)
tion (CPR) is initiated. Commotio cordis is managed in a manner or between the upper (brachia! artery) and lower extremities
similar to cardiac arrests resulting from myocardial infarction (femoral artery). Blood pressures, if measured, may be higher in
rather than those resulting from trauma and blood loss. The car- the upper extremities than the lower extremities, comprising the
diac rhythm should be determined as expeditiously as possible, signs of a pseudo-coarctation (narrowing) of the aorta.
with rapid defibrillation administered if ventricular fibrillation
is identified. Prognosis is poor, with the chance of survival at Definitive diagnosis of aortic disruption requires radio-
15% or less.45 Virtually all s urvivors of this condition received graphic imaging in the hospital. Plain chest radiographs may
both rapid, bystander-initiated CPR and immediate defibrilla- demonstrate a variety of signs suggesting the injury is present .
tion, often with an automated external defibrillator. Precordial The most reliable of these is widening of the mediastinum. The
thumps have not been shown to consistently terminate ventricu- injury can be definitively demonstrated with aortography, CT of
lar fibrillation; however, they may be attempted if a defibrillator the chest, and transesophageal echocardiography.48
is not immediately available. The initiation of CPR and electri-
cal defibrillation should not be delayed to perform a precordial Management
thump.47 Ifimmediate attempts at defibrillation are unsuccessful,
the airway is secured and IV access initiated. Epinephrine and Management of traumatic aortic disruption in the field is support-
antidysrhythmic pharmacologic agents may be administered as ive. A high index ofsuspicion for its presence is maintained when
outlined in medical cardiac arrest protocols. the appropriate mechanism exists. High-concentration supple-
mental oxygen is administered and IV access is obtained, except
Traumatic Aortic Disruption in cases ofextremely short transport times. Communication with
the receiving facility about the mechanism and suspicion for
Traumatic aortic disruption results from a deceleration/ aortic disruption should occur at the earliest opportunity. Strict
acceleration mechanism of significant force.48 Examples include blood pressure control is imperative to the successful outcome
high-speed frontal-impact motor vehicle crashes and high falls in of these injuries (Figure 12-24). Traumatic aortic disruption rep-
which the patient lands flat. resents another situation in which balanced resuscitation is clini-
cally useful. Fluid resuscitation that results in normal or elevated
The aorta arises from the upper portion of the heart in blood pressure may result in rupture of the remaining tissue of
the mediastinum. The heart, ascending aorta, and aortic arch

CHAPTER 12 Thoracic Trauma 3 5 3

Left common Left subclavian artery
carotid artery
Pseudo-
Aortic arch aneurysm

A

Left common
carotid artery

Descending
aorta

D

Figure 12-23 A. The descending aorta is a fixed structure that moves with the thoracic spine. The arch, aorta, and heart are freely movable.
Acceleration of the torso in a lateral-impact collision or rapid deceleration of the torso in a frontal-impact collision produces a different rate
of motion between the arch-heart complex and the descending aorta. This motion may result in a tear of the inner lining of the aorta that
is contained within the outermost layer, producing a pseudoaneurysm . B. Tears at the junction of the arch and descending aorta may also
resu lt in a complete rupture. leading to immediate exsanguination in the chest. C and D. Operative photograph and drawing of a traumatic
aortic tear.

Source: C., D. Courtesy Norman Mcswain, MD, FACS, NREMT-P.

Figure 12-24

Caution: When performing interhospital transfer of (e.g., esmolol, metoprolol), to maintain the blood pressure
patients with suspected aortic disruption, it is important at a lower level, typically a mean arterial pressure of 70
not to raise the patient's blood pressure aggressively mm Hg or less. Such therapy typically requires invasive
because this may lead to exsanguinating hemorrhage (see monitoring, such as insertion of an arterial line, so that
t he Shock chapter). Many of these patients may be given blood pressure can be monit ored much more carefully.
infusions of medications, such as beta blockers

3 5 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

the aorta and rapid exsanguillation. Iftransport times are longer, Respiratory function may be significantly impaired because of
blood pressure management should be guided by the highest preferential airflow across the lesion as well as the pressure.
blood pressure obtained, typically in the right arm. Control of Positive-pressure ventilation efforts may worsen the tension.
both blood pressure and contractile force may be accomplished Penetrating trauma is more likely to cause this injury than blunt
with the administration of beta blockers.49 trauma. However, blunt injury of high energy may also cause tra-
cheobronchial disruption.50

Tracheobronchial Disruption Assessment

Tracheobronchial disruption is an uncommon, but potentially Assessment of the patient with tracheobronchial disruption
highly lethal, entity.49 All lacerations of the lung involve disrup- demonstrates an individual in obvious distress. The patient may
tion of airways to some degree; however, in these cases, the be pale and diaphoretic and will demonstrate signs of respira-
intrathoracic portion of the trachea itself or one of the main or tory distress, such as use of accessory muscles of respiration,
secondary bronchi is disrupted. This disruption results in high grunting, and nasal flaring. Extensive subcutaneous emphy-
flow of air through the injury into the mediastinum or pleural sema, especially in the upper chest and neck, may be identi-
space (Figure ]2-25). Pressure rapidly accumulates, resulting in fied (Figure 12-26). Although traditionally taught as important
tension pneumothorax or even tension pneumomediastinum, findings, jugular venous distension may be obscured by sub-
which is similar to cardiac tamponade except that it results cutaneous emphysema, and deviation of the trachea may only
from the presence of air and not blood or fluid. Unlike the usual be noted upon palpation of the trachea in the jugular notch.
situation in tension pneumothorax, needle thoracostomy may Ventilatory rate will be elevated, and oxygen saturation may
result in the continuous flow ofair through the catheter and may be diminished. The patient may or may not be hypotensive and
fail to relieve the tension. This is caused by the ongoing high may cough up blood (hemoptysis). The hemorrhage associated
flow of air across these major airways into the pleural space.

Figure 12-25 Tracheal or bronchial rupture. Positive-pressure ventilation (PPV) can directly force large amounts of air t hrough the trachea or
bronchus, rapidly producing a tension pneumothorax.

CHAPTER 12 Thoracic Trauma 3 5 5

asphyxia, upper chest) as patients who have been strangled.
Unlike strangled patients, however, traumatic asphyxia patients
do not suffer from true asphyxia (cessation of air and gas
exchange). The similarityin appearance to strangulation patients
results from the impaired venous return from the head and neck
that is present in both groups of patients.

The mechanism for traumatic asphyxia is an abrupt, signif-
icant increase in thoracic pressure resulting from a crush to the
torso (e.g., car falling off a jack onto the patient's chest). This
pressure results in blood being forced back out of the heart and
into the veins in a retrograde direction. Because the veins of the
arms and lower extremities contain valves, backward flow into
the extremities is limited. However, the veins of the neck and
head lack such valves, and blood is preferentially forced into
these areas. Subcutaneous venules and small capillaries rupture
and blood leaks out, resulting in the purplish discoloration ofthe
skin. Rupture of small vessels in the brain and retina may result
in brain and eye dysfunction. Traumatic asphyxia is reported to
be a marker for blunt cardiac rupture.51

Assessment

Figure 12-26 Patient with trauma to the anterior neck causing The hallmark of traumatic asphyxia is plethora, a bodily condi-
a tracheal disruption and subcutaneous emphysema of the face tion characterized by an excess of blood and turgescence (i.e.,
(eyelids) and neck. swelling and distension of blood vessels), with a reddish col-
oration of the skin. This appearance is most prominent above
Source: Photograph provided courtesy of J.C. Pitteloud M.D., Switzerland. the level of the crush (Figure 12-27). The skin below the level of
injury is normal. Because of the force applied to the chest neces-
sary to cause this injury, many of the injuries already discussed
in this chapter may be present, as well as injuries to the spine
and spinal cord.

with penetrating trauma may not be present in the blunt cases, Management
but hemothorax is a possibility in both penetrating and blunt
trauma. Management is supportive. High-concentration oxygen is admin-
istered, IV access obtained, and judicious ventilatory support
Management provided, ifindicated. The reddish-purple discoloration typically
fades within 1 to 2 weeks in survivors.

Successful management oftracheobronchial disruption requires Diaphragmatic Rupture
administration of supplemental oxygen andjudicious use ofven-
tilatory assistance. Ifassisted ventilation makes the patient more Small lacerations ofthe diaphragm may occur in penetrating inju-
uncomfortable, only oxygen is administered and the patient is ries to the thoracoabdominal region.1 Because the diaphragm rises
transported as quickly as possible to an appropriate facility. and falls with respiration, any penetration that is below the level
Continuous monitoring for signs ofprogression toward a tension of the nipples anteriorly or the level of the scapular tip posteri-
pneumothorax is imperative, and rapid needle decompression orly is at risk for having traversed the diaphragm. Generally, these
should be attempted if these signs present. Complex advanced lesions do not present any acute problems on their own, but they
airway management, such as selective main bronchus intuba- usually require surgical repair because of the risk in the future for
tion, is difficult to accomplish in the field and has the potential herniation and strangulation of abdominal contents through the
for worsening a major bronchial injury. defect. Significant injuries to thoracic or abdominal organs may
accompany these otherwise apparently innocuous injuries.
Traumatic Asphyxia
Blunt diaphragmatic rupture results from the application
Traumatic asphyxia is so named because the victims physically of sufficient force to the abdomen to increase abdominal pres-
resemble strangulation patients. They exhibit the same bluish sure acutely, abruptly, and sufficiently to disrupt the diaphragm.
discoloration of the face and neck (and in the case of traumatic Unlike the small tears that usually accompany penetrating injury,
the tears resulting from blunt mechanisms are frequently large

3 5 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Figure 12-28 Diaphragmatic rupture may cause the bowel or other
structures to herniate through t he tear, causing partial compression
of the lung and respiratory distress.

Management

Figure 12-27 Child with traumatic asphyxia . Note the purple Prompt recognition that diaphragmatic rupture may be present
discoloration, particularly on t he chin, and the multiple petecchiae on is necessary. Supplemental oxygen in high concentration should
the face and forehead. be administered and ventilation supported as necessary. The
patient should be rapidly transported to an appropriate facility.
Source: Photograph provided courtesy of J.C. Pittelo ud M.D., Switzerland.
Prolonged Transport

and allow acute herniation of the abdominal viscera into the Priorities for managing patients with lmown or suspected tho-
chest cavity1 (Figure 12-28). Respiratory distress results from racic injuries during prolonged transport remain fundamental,
the pressure of the herniated organs on the lungs, preventing including managing the airway, supporting ventilation and oxy-
effective ventilation, as well as from contusion of the lungs. This genation, controlling hemorrhage, and providing appropriate
impairment of ventilation may be life threatening. In addition volume resuscitation. When faced with a prolonged transport,
to the ventilatory dysfunction, rib fractures, hemothorax, and prehospital care providers may have a lower threshold for secur-
pneumothorax may occur. IItjury of intra-abdominal organs may ing the airway with endotracheal intubation. Indications for
also accompany the injury to the diaphragm, including injuries performing endotracheal intubation include increasing respira-
to the liver, spleen, stomach, or intestines, as these organs are tory distress or impending respiratory failure (after exclusion or
forced through the tear in the diaphragm into the pleural cavity. treatment of a tension pneumothorax), a flail chest, open pneu-
These patients are frequently in acute distress and require rapid mothorax, or multiple rib fractures. Oxygen should be provided
intervention to recover. to maintain oxygen saturation at 95%or greater.

Assessment Ventilations should be assisted as necessary. Pulmonary
contusions worsen over time, and the use of CPAP, positive
Assessment frequently reveals a patient in acute respiratory dis- end-expiratory pressure (PEEP) with a transport ventilator, or
tress who appears anxious, tachypneic, and pale. The patient PEEP valves with bag-mask device may facilitate oxygenation.
may have contusions of the chest wall, bony crepitus, or sub- Any patient with significantthoracic trauma may have or develop
cutaneous emphysema. Breath sounds on the affected side may a tension pneumothorax, and ongoing assessment should look
be diminished, or bowel sounds may be auscultated over the for the hallmark signs. In the presence of decreased or absent
chest. The abdomen may be scaphoid ifenough ofthe abdominal breath sounds, worsening respiratory distress, difficulty squeez-
contents have herniated into the chest. ing the bag-mask device, increasing peak inspiratory pressures
in patients on a ventilator, and hypotension, pleural decompres-
sion should be performed. A tube thoracostomy (insertion of a

CHAPTER 12 Thoracic Trauma 357

chest tube) may be performed by authorized personnel, typically Patients with severe pain from multiple rib fractures may
air medical flight crews, if the patient requires needle decom- benefit from small doses of narcotics titrated intravenously. If
pression or is found to have an open pneumothorax. Intravenous narcotic administration results in hypotension and respiratory
access should be secured and IV fluids administered judiciously. failure, volume resuscitation and ventilatory support should be
provided.
Patients with suspected intrathoracic, intra-abdominal, or
retroperitoneal hemorrhage should be maintained with systolic Patients with cardiac dysrhythmias associated with blunt
blood pressure in the range of 80 to 90 mm Hg. Overaggressive cardiac injury may benefit from the use of antidysrhythmic
volume resuscitation may significantly worsen pulmonary contu- medications. Any interventions performed should be carefully
sions, as well as lead to recurrent internal hemorrhage (see the documented on the patient care report (PCR), and the receiving
Shock chapter). facility must be made aware of the procedures.

• Thoracic injuries are particularly significant because of the potential for compromise of respiratory and cir-
culatory function and because thoracic injuries are frequently associated with multisystem trauma.

• Patients with chest injury need to be managed aggressively and transported quickly to definitive care.
• Particular attention should be paid to the administration ofsupplemental high-concentration oxygen and the

need for ventilatory support in any patient suspected of having chest trauma.
• Pulse oximetry and sidestream or in-line waveform capnography are useful adjuncts for assessing ventila-

tory status and responses to therapy.
• Signs of tension pneumothorax should be carefully sought because treatment in the field with needle decom-

pression may correct this possible, rapidly fatal problem.
• Because of the high risk of multisystem trauma in patients with blunt thoracic trauma, spinal immobilization

is considered and hemorrhage is controlled.
• Intravenous access should be obtained en route to the medical facility and fluid therapy administered with

appropriate goals in mind.
• Electrocardiographic monitoring may suggest blunt cardiac injury.
• Although many thoracic injuries can be managed without surgical intervention, the patient with a chest

injury must still be evaluated and managed at an appropriate medical facility.

You and your partner are dispatched to an industrial construction area for a worker who was struck by a piece of metal. Upon arrival you
are met at the gate by the site saf ety officer, who leads you to an interior work area. En rout e to the work area, the safety officer states
the patient was helping to install metal studs. When he turned to grab another stud, he ran into the end of a stud his partner had just
trimmed, cutting through his shirt and puncturing his chest.

In the work area you find an approximately 35-year-old man sitting upright on a pile of lumber, leaning forward and holding a rag
to the right side of his chest. You ask t he patient what happened, and he tries to tell you but has to stop after every five to six words to
catch his breath. As you move the rag, you not ice an open laceration approximately 2 inches (5 centimeters) long w ith a small amount
of blood-tinged, "bubbling" fluid . The patient is diaphoretic and has a rapid radial pulse. Decreased breath sounds are noted on the
right side with auscultation. No other abnormal physical findings are noted.

• Is this patient in respiratory distress?
• Does he have life-threatening injuries?
• What interventions should you undertake in the field?
• What modal ity shou ld be used to transport t his patient?
• How would a different location (e.g., rural) impact your management and plans during prolonged transport?
• What other injuries do you suspect?

3 5 8 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

The scene report, patient complaints, and physical examination lead you to suspect t hat this patient may have serious and potentially
life-threatening injuries. He is awake and speaking coherently, indicating that he has a stable airway. He is experiencing severe respiratory
distress. The location of the w ound, bubbling fluid, and decreased breat h sounds indicate an open pneumothorax.

You move quickly to apply an occlusive dressing, provide the patient with supplemental oxygen, and consider ventilatory assistance
with a bag-mask device as necessary. The first priorities in this scenario are to recognize the seriousness of t he injuries, stabilize t he
patient. and initiate transfer to an appropriate facility. Given t his patient's respiratory distress and findings, he is at significant risk for
complications. Transport to the closest trauma center is appropriat e. Intravenous access should be obtained en route.

There is risk for respiratory deterioration, and the pat ient's ventilatory status needs to be monitored closely. Signs of progressing
circulatory compromise and respiratory distress would prompt you to f irst remove the occlusive dressing and, if there is no improvement,
to perform needle decompression. If transport t ime will be extended, air transport should be considered.

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8. Pressley CM, Fry WR, Philip AS, et al. Predicting outcome of
patients with chest wall injury.Am J Surg. 2012;204(6):900-904. 22. Holcomb JB, McManus JG, Kerr ST, Pusateri AE. Needle versus
tube thoracostomy in a swine model of traumatic tension hemo-
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point for mortality. Surgery. 2005;138:717- 725.
23. Butler KL, Best IM, Weaver WL, et al. Pulmonary artery injury and
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influences m ortality? Am J Surg. 2011;202(5);598-604. sion pneumothorax. J Trauma. 2003;54:610.

11. Richardson JD, Adams L, Flint LM. Selective management of flail 24. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alterna-
chest and pulmonary contusion. An n Surg. 1982;196:481. tive sites for needle decompression of tension pneumothorax. Arch
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12. Di Bartolomeo S, Sanson G, Nardi G, eta!. A population-based study
on pneumothorax in severely traumatized patients. J Trauma. 25. Inaba K, Branco BC Exkstein M, et al. Optimal positioning for
2001;51(4):677. emergent needle thoracostomy: a cadaver-based study. J Trauma.
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of early intervention outcome. Acta Anaesthesiol Scan d Suppl. 26. Netto FA, Shulman H, Rizoli SB, et al. Are needle decompressions
1997;110:71. for tension pneumothoraces being performed appropriately for
appropriate indications? Am J Em Med. 2008;26;597-602.
14. Barone JE, Pizzi WF, Nealon TF, et al. Indications for intubation in
blunt chest trauma. J Trauma. 1986;26:334.

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27. Riwoe D, Poncia H. Subclavian artery laceration: a serious compli- 45. Perron AD, Brady WJ, Erling BF. Commodio cordis: an underappre-
cation of needle decompression. Em M ed Aust. 2011;23:651--053. ciated cause of sudden cardiac death in young patients: assessment
and management in the ED. Am J Emerg M ed. 2001;19(5):406--409.
28. Beckett A, Savage E, Pannell D, et al. Needle decompression for
tension pneumothora.x in tactical combat casualty care: do cathe- 46. Madias C, Maron BJ, Weinstock J, et al. Commotio cordis-sudden
ters placed in the midaxillary line kink more often than those in the cardiac death with chest wall impact. J Cardiovasc Electrophysiol.
midclavicular line? J Trauma. 2011;7l:S408-S412. 2007;18(1):115-122.

29. Martin M, Satterly S, Inaba K, Blair K Does needle thoracostomy 47. 2010 American Heart Association Guidelines for Cardiopulmonary
provide adequate and effective decompression of tension pneumo- Resuscitation and Emergency Cardiovascular Care Science.
thorax? J Trauma. 2012;73(6):1410-1415. Circulati on. 2010;122;S745-S746.

30. Davis DP, Pettit K, Rum CD, et al. The safety and efficacy of pre- 48. Mattox KL, Wall MJ, Lemaire SA. Injury to the thoracic great ves-
hospital needle and tube thoracostomy by aeromedical personnel. sels. In: Mattox KL, Feliciano DV, Moore EE. Trauma. 5th ed. New
Prehosp Emerg Care. 2005;9:191. York, NY: McGraw-Hill; 2004.

31. Etoch SW, Bar-Natan MF, Miller FB, et al. Tube thoracostomy: fac- 49. Fabian TC. Roger T. Sherman Lecture: advances in the management
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2009;75(4):273-278.
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EE. Trauma. 5th ed. New York, NY: McGraw-Hill; 2004:555.
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1999;67(5):1274. suggested Reading

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3 6 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Thoracic Trauma Skills

Needle Decompression

Principle: To decease intrathoracic pressure from a tension pneumothorax affecting the
patient's breathing, ventilation, and circulation.

In patients with increasing intrathoracic pressure from a developing tension pneumothorax, the side of the thoracic cavity t hat
has the increased pressure should be decompressed. If this pressure is not relieved, it will progressively limit the patient's venti-
latory capacity and cause inadequate venous return, producing inadequate cardiac output and death.

In patients in whom an open pneumothorax has been treated by the use of an occlusive dressing and a tension pneu-
mothorax develops, decompression can usually be achieved through the wound, which provides an existing opening into t he
thorax. Opening the occlusive dressing over the wound for a few seconds should initiate a rush of air out of the wound as
increased pressure in the thorax is relieved.

Once this pressure has been released, the wound is resealed with the occlusive dressing to allow for proper alveolar ven-
tilat ion and to stop air from "sucking" into the wound . The patient should be monitored carefully and, if any signs of tension
recur, the dressing should be "burped" again to release the intrathoracic pressure.

Decompression in a closed-tension pneumothorax is achieved by providing an opening-a thoracostomy-in the affected
side of the chest. Different methods for performing a thoracostomy exist. Because needle t horacostomy is the most rapid
method and does not require special equipment, it is the preferred method for use in the field.

Needle decompression carries minimal risk and can greatly benefit the patient by improving oxygenation and circulation .
Needle decompression should be performed only when the following three criteria are met:

1. Evidence of worsening respiratory distress or difficulty with a bag-mask device
2. Decreased or absent breath sounds
3. Decompensated shock (systolic blood pressure less than 90 mm Hg)

Necessary equipment for needle chest decompression includes a needle, a syringe, 1/2-inch adhesive tape, and alcohol
swabs. The needles should be large-bore, over-the-needle IV catheters between 10 and 14 gauge, at least 3.5 inches (8 cm) in
length. A 16-gauge catheter can be used if a larger bore is not available.

One prehospital care provider attaches the needle to the syringe while a second prehospital care provider auscultates t he
patient's chest to confirm which side has the tension pneumothorax, which is indicated by absent or diminished breath sounds.

After confirmation of a tension pneumothorax, • The site is swabbed with an antiseptic w ipe.
• t he anatomic landmarks are located on the

affected side (midclavicular line, second or third
intercostal space).

CHAPTER 12 Thoracic Trauma 361

Thoracic Trauma Skills ccontinuedJ

The skin over the site is stretched between the • Once the needle enters into the thoracic cavity,
• fingers of the nondominant hand. The needle air will escape into the syringe, and the needle
should not be advanced further.
and syringe are positioned over the top of
the rib.

The catheter should be left in place and the • After the needle is removed, the catheter is
• needle removed, with care not to kink the taped in place with adhesive tape. After secu ring
the catheter, the chest is auscultated to check
catheter. As the needle is removed, a rush of air for increased breath sounds. The patient is
from the hub of the catheter should be heard. monitored and transported to an appropriate
If no air escapes, the catheter should be left in facility. The prehospital care provider need not
place to indicate that needle decompression of waste time applying a one-way valve. Needle
the chest was attempted.
decompression may need to be repeated if the
catheter becomes occluded with a blood clot
and tension pneumothorax reoccurs.

At the completion of this chapter, the reader will be able to do the following:

• Analyze scene assessment data to determine the • Understand appropriate field management
level of suspicion for abdominal trauma. decisions for patients w ith suspected abdominal
trauma, including those with impaled objects,
• Recognize the physical examination findings evisceration, and external genital trauma.
indicative of intra-abdominal bleeding.
• Correlate the anatomic and physiologic
• Correlate external signs of abdominal injury changes associated w ith pregnancy to the
to the potential for specific abdominal organ pathophysiology and management of trauma.
inj uries.
• Discuss the effect s of maternal trauma on the
• Anticipate the pathophysiologic effects of a blunt fetus and the priorities of management.
or penetrating injury to the abdomen.

• Identify the indications for rapid intervention and
transport in the context of abdominal trauma.

CHAPTER 13 Abdominal Trauma 363

You are called to a construction site for a male patient in his mid-20s who fell 3 hours earlier and is now complaining of increasing
abdominal pain. He states that he tripped on a piece of wood at the site and fell, striking his left lower chest and abdomen on some
stacked wood . The patient notes moderate pain over his lower left rib cage when he takes deep breaths and complains of mild difficulty
breathing. His coworkers wanted to call for assistance when he fell, but he said the symptoms weren't so bad and told them to hold off.
He states that the discomfort has been increasing in intensity and that he is now feeling lightheaded and weak.

You find the patient sitting on the ground in visible discomfort. He is holding the left side of his lower chest and upper abdomen. He
has a patent airway, a ventilatory rate of 28 breaths/minute, a heart rate of 124 beats/minute, and a blood pressure of 94/58 millimeters
of mercury (mm Hg). The patient's skin is pale and diaphoretic. You lay him down. and on physical examination, he has tenderness on
palpation of the left lower ribs without obvious bony crepitus. His abdomen is nondistended and soft to palpation, but he has tenderness
and voluntary guarding in the left upper quadrant. No external ecchymosis or subcutaneous emphysema is present.

• What are t he patient's possible injuries?
• What are t he priorities in the care of this patient?
• Are signs of peritonitis present?

• Introduction the diaphragm; its boundaries include the anterior abdominal
wall, the pelvic bones, the vertebral column, and the muscles of
" - , / Unrecognized abdominal injury is one of the the abdomen and flanks. The abdominal cavity is divided into
major causes of preventable death in the two regions based upon the relationship to the peritoneum,
trauma patient. Because of the limitations of which covers many of the organs of the abdomen. The perito-
prehospital assessment, patients with suspected abdominal inju- neaI cavity (the "true" abdominal cavity) contains the spleen,
ries are best managed by prompt transport to the closest appro- liver, gallbladder, stomach, portions of the large intestine (trans-
priate facility. verse and sigmoid colon), most of the small intestines (primarily
the jejunum and ileum), and female reproductive organs (uterus
Early death from severe abdominal trauma typically results and ovaries) (Figure 13-1). The retroperitoneal space is the area
from massive blood loss caused by either penetrating or blunt in the abdominal cavity that is located behind the peritoneum
injuries. Any patient with unexplained shock after sustaining a and contains the kidneys, ureters, inferior vena cava, abdominal
traumatic injury to the trunk of the body should be assumed to aorta, pancreas, much of the duodenum, ascending and descend-
have an intra-abdominal hemorrhage until proven otherwise, ing colon, and rectum (Figure 13-2). The urinary bladder and
which can only be accomplished by appropriate diagnostic stud- male reproductive organs (penis, testes, and prostate) lie inferior
ies in the hospital. Complications and death may occur from liver, to the peritoneal cavity.
spleen, colon, small intestine, stomach, or pancreatic injuries that
were not initially detected. The absence of local signs and symp- A portion of the abdomen lies in the lower thorax. This
toms does not rule outthe possibility ofabdominal trauma, as they is because the dome shape of the diaphragm allows the upper
often take time to develop and are especially difficult to identify abdominal organs to rise up into the lower chest. This superior
in the patient whose level of consciousness is altered by alcohol, portion of the abdomen, sometimes referred to as the thora-
drugs, or traumatic brain injury (TBI). Consideration of the kine- coabdomen, is protected in front and along the flanks by the
matics will raise the index of suspicion of the alert prehospital ribs and in back by the vertebral column. The thoracoabdomen
care provider to possible abdominal trauma and intra-abdominal
hemorrhage. It is not necessary to be concerned with pinpointing contains the liver, gallbladder, spleen, and parts of the stomach
the exact extent ofabdominal trauma, but rather to recognize the anteriorly and the lower lobes of the lungs posteriorly, sepa-
likelihood ofinjury and to treat the clinical findings. rated by the diaphragm. Because of their location, the same
forces that fracture ribs may injure the underlying lungs, liver,
Anatomy or spleen.

The abdomen contains the major organs of the digestive, The relationship of these abdominal organs to the lower
endocrine, and urogenital systems and major vessels of the portion of the thoracic cavity changes with the respiratory cycle.
circulatory system. The abdominal cavity is located below At peak expiration, the dome of the relaxed diaphragm rises to
the level of the fourth intercostal space (nipple level in the male),
providing greater protection to abdominal organs from the rib
cage. Conversely, at peak inspiration, the dome of the contracted

3 6 4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Vermiform appendix

Figure 13-1 The organs inside the peritoneal cavity frequently produce peritonitis when injured. Organs in the peritoneal cavity
include solid organs (spleen and liver), hollow organs of the gastrointestinal tract (stomach, sma ll intestine, and colon), and the
reproductive organs.

diaphragm lies at the level of the sixth intercostal space; the high correlation of organ location to pain response. The right
inflated lungs almost fill the thorax and largely push these upper quadrant includes the liver and gallbladder, the left upper
abdominal organs out from under the rib cage. Thus, the organs quadrant contains the spleen and stomach, and the right lower
injured by penetrating trauma to the thoracoabdomen may dif- quadrant and left lower quadrant contain primarily the intes-
fer depending upon which phase of respiration the patient is in tines, the distal ureters, and, in women, the ovaries. A portion
when injured (Figure 13-3). of the intestinal tract exists in all four quadrants. The urinary
bladder and the uterus in women are midline between the lower
The most inferior portion of the abdomen is protected quadrants.
on all sides by the pelvis. This area contains the rectum, a
portion of the small intestine (especially when the patient is Pathophysiology
upright), the urinary bladder, and, in the female, the repro-
ductive organs. Retroperitoneal hemorrhage associated with Dividing the abdominal organs into hollow, solid, and vascular
a fractured pelvis is a major concern in this portion of the (blood vessel) groups helps explain manifestations of injury to
abdominal cavity. these structures. When injured, solid organs (liver, spleen) and
blood vessels (aorta, vena cava) bleed, whereas hollow organs
The abdomen between the rib cage and the pelvis is pro- (intestine, gallbladder, urinary bladder) primarily spill their con-
tected only by the abdominal muscles and other soft tissues tents into the peritoneal cavity or retroperitoneal space, although
anteriorly and laterally. Posteriorly, the lumbar vertebrae and the they too bleed but often not as briskly as do solid organs. Loss
thick, strong paraspinal and psoas muscles located along the of blood into the abdominal cavity, regardless of its source, can
length of the spine provide more protection (Figure 13-4). contribute to or can be the primary cause of the development of
hemorrhagic shock. The release ofacids, digestive enzymes, and/
For purposes of patient assessment, the surface of the or bacteria from the gastrointestinal tract into the peritoneal cav-
abdomen is divided into four quadrants. These quadrants are ity results in peritonitis (inflammation of the peritoneum or the
formed by drawing two lines: one in the middle from the tip lining of the abdominal cavity) and sepsis (systemic infection)
of the xiphoid to the symphysis pubis and one perpendicu-
lar to this midline at the level of the umbilicus (Figure 13-5).
Knowledge of anatomic landmarks is important because of the

Inferior vena cava CHAPTER 13 Abdominal Trauma 3 6 5

_:.::1,,--~~=?.- Superior mesenteric
artery and vein

External iliac artery
External iliac vein

Figure 13-2 The abdomen is divided into two spaces: peritoneal cavity and retroperitoneal space. The retroperitoneal space includes t he
portion of the abdomen behind the peritoneum. Because the retroperitoneal organs are not w ithin t he peritoneal cavity, inj ury to these
structures generally does not produce peritonitis; however, injury to the large blood vessels and solid organs may produce rapid and massive
hemorrhage.

Inhalation Expiration

Diaphragm B

A

Figure 13-3 Relationship of abdominal organs to the thorax in different phases of respiration in a patient wit h a stab w ound.
A. Expiration . B. Inhalation.

366 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Lesser Abdominal Liver hours. Bleeding from intestinal injury is typically minor, unless
Stomach omentum aorta the larger blood vessels in the mesentery (the folds of peritoneal
tissue that attach the bowel to posterior wall of the abdominal
Left kidney Pancreas Paraspinal cavity) are damaged.
muscles
Injuries to the abdomen can be caused by either pene-
Figure 13-4 This transverse section of the abdominal cavity trating or blunt trauma. Penetrating trauma, such as a gun-
provides an appreciation of the organ's positions in the shot or stab wound, is more readily visible than blunt trauma.
anteroposterior direction. Multiple organs may be damaged as a result of penetrating
trauma, more commonly with gunshot wounds versus stab
Costal margin Rib cage wounds given the high energy associated with the "missile"
Liver type injury and the relatively low energy and limited length
"r ~~~~~i--- Xpriophcoeisds of most objects used to stab a patient. A mental visualization
Colon of the potential trajectory of the penetrating object, such as a
~:....~-- Spleen bullet or the path of a knife blade, can help identify possible
injured internal organs.
--''-'-'-...~--Stomach
The diaphragm extends superiorly to the fourth intercos-
Left upper tal space anteriorly, the sixth intercostal space laterally, and
"---- quadrant the eighth intercostal space posteriorly during maximum expi-
ration (see Figure 13-3). Patients who sustain a penetrating
Figure 13-5 As with any part of the body, the better the injury to the thorax below these anatomic locations may also
description of pain, tenderness, guarding, and other signs, the more have sustained an abdominal injury. Penetrating wounds of the
accurate the diagnosis. The most common system of identification flanks and buttocks may involve organs in the abdominal cav-
divides the abdomen into four quadrants: left upper, right upper, left ity as well. These penetrating injuries may cause bleeding from
lower, and right lower. a major vessel or solid organ and perloration of a segment of
the intestine, the most frequently injured organ in penetrating
if not recognized and promptly treated by surgical intervention. trauma.
Because urine and bile are generally sterile (do not contain bac-
teria) and do not contain digestive enzymes, perloration of the Blunt trauma injuries are often more challenging to recog-
gallbladder or urinary bladder does not produce peritonitis as nize than those caused by penetrating trauma. These injuries
quickly as material spilled from the intestine. Similarly, because to abdominal organs result from either compression or shear
it also lacks acids, digestive enzymes, and bacteria, blood in forces. In compression injuries, the organs of the abdomen
the peritoneal cavity does not cause peritonitis for a number of are crushed between solid objects, such as between the steer-
ing wheel and spinal column. Shear forces create rupture
of the solid organs or rupture of blood vessels in the cavity
because of the tearing forces exerted against their supporting
ligaments. The liver and spleen can shear and bleed easily, and
blood loss can occur at a rapid rate. Increased intra-abdominal
pressure produced by compression can rupture the diaphragm,
causing the abdominal organs to move upward into the pleural
cavity (see the Kinematics of Trauma and the Thoracic Trauma
chapters). The intra-abdominal contents forced into the chest
cavity can compromise lung expansion and affect both respi-
ratory and cardiac function (Figure 13-6). Although rupture of
each half of the diaphragm is now believed to occur equally,
rupture of the left hemidiaphragm (half of the diaphragm) is
diagnosed more often, as the underlying liver on the right side
often prevents herniation of abdominal contents into the right
chest and makes the diagnosis of a right-side diaphragm injury
more difficult.

Pelvic fractures may be associated with the loss of large
volumes of blood caused by damage to the many smaller blood
vessels adjacent to the pelvis. Otherinjuries associated with pelvic
fractures include damage to the urinary bladder and the rectum,
as well as injuries to the urethra in the male and the vagina in the
female.

CHAPTER 13 Abdominal Trauma 367

to penetrate the peritoneal cavity than projectiles fired from a
handgun, rifle, or shotgun.

When the peritoneum is penetrated, stab wounds are most
likely to injure the liver (40%), small bowel (30%), diaphragm
(200,f>), and colon (15%), whereas gunshot wounds most com-
monly damage the small bowel (500,i>), colon (40<>A>), liver (30%),
and abdominal vessels (25%).1 Because of the thicker muscula-
ture of the back, penetrating trauma to the back is less likely to
result in injuries of intraperitoneal structures than wounds to the
anterior abdominal wall. Overall, only about 15% of patients with
stab wounds to the abdomen will require surgical intervention,
whereas about 85% of patients with gunshot wounds will need
surgery for definitive management of their abdominal injuries.
Tangential gunshot wounds may pass through subcutaneous tis-
sues but never enter the peritoneal cavity. Explosive devices may
also propel fragments that penetrate the peritoneum and injure
internal organs.

Figure 13-6 With increased pressure inside the abdomen, the Blunt Trauma
diaphragm can rupture, allowing intra-abdominal organs such as the
stomach or small intestine to herniate into the chest. Numerous mechanisms lead to the compression and shear
forces that may damage abdominal organs. A patient may expe-
Assessment rience considerable deceleration or compression forces when
involved in motor vehicle and motorcycle crashes, when struck
The assessment of abdominal injury can be difficult, especially or run over by a vehicle, or after falling from a significant
with the limited diagnostic capabilities available in the prehospi- height. Although abdominal organs are most often injured in
tal setting. A high index ofsuspicion for abdominal injury should events associated with significant kinetic injury, such as those
develop from a variety ofsources ofinformation, including kine- with rapid deceleration or severe compression, abdominal inju-
matics, the :findings from the physical examination, and input ries may result from more innocuous-appearing mechanisms,
from the patient or bystanders. such as assaults, falls down a flight ofstairs, and sporting activ-
ities (e.g., being tackled in football). Any protective devices or
Kinematics gear used by the patient should be noted, including seat belts,
air bags, or sports padding.
As with other types of trauma, knowledge of the mechanism of
injury, whether blunt or penetrating, plays an important role in Compression of a solid organ may result in splitting ofits
shaping the prehospital care provider's index of suspicion for structure (e.g., hepaticlaceration); whereas suchforces applied
abdominal trauma. to a hollow structure, such as a loop of bowel or the bladder,
may cause the structure to burst open ("rupture"), spilling its
Penetrating Trauma contents into the abdomen. Shearing forces may result in tears
of structures at sites of tethering to other structures, such as
Most penetrating trauma in the civilian setting results from stab where the more mobile small bowel joins the ascending colon,
wounds and gunshot wounds from handguns. Occasionally, which is fixed in the retroperitoneum. The organs most com-
impalement with or onto an object occurs when, for example, monly injured following blunt trauma to the abdomen include
someone falls onto a projecting piece of wood or metal. These the spleen (40-55%), liver (35-45%), and small bowel (5-10%).
low to moderate kinetic energy forces lacerate or cut abdomi- Not all injuries to solid organs require surgical intervention
nal organs along the pathway of the knife, projectile, or pene- (Figure 13-7). Many of these types of solid organ injuries are
trating object. High-velocity injuries, such as those created by now observed carefully in the hospital, as they will often stop
high-powered rifles and assault weapons, tend to create more bleeding on their own.
serious injuries because ofthe larger temporary cavities created
as the projectile moves through the peritoneal cavity. Projectiles History
may strike bones (ribs, spine, or pelvis), resulting in fragments
that may perforate internal organs. Stab wounds are less likely History may be obtained from the patient, family, or bystand-
ers and should be documented on the patient care report and
relayed to the receiving facility. In addition to the components of
the SAMPLE history (symptoms, allergies and age, medications,


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